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SURGERY  OF  THE  UPPER  ABDOMEN 


DEAVER  AND  ASHHURST 


VOLUME  II 

IN  ACTIVE  PREPARATION 

SURGERY  OF  THE  LIVER,  GALL 
BLADDER,  PANCREAS,  AND  SPLEEN 


SURGERY   OF  THE 
UPPER  ABDOMEN 


IN  TWO  VOLUMES 


BY 


JOHN  B.   DEAVER,  M.D.,  LL.D. 

Surgeo?i-in- Chief  to  the  German   Hospital,  Philadelphia 


AND 


ASTLEY  PASTON  COOPER  ASHHURST,  M.D. 

Surgeon  to  the   Oiit-Palient  Department  of  the  Episcopal  Hospital^   Philadelphia 


VOLUME  I 
SURGERY  OF  THE  STOMACH  AND  DUODENUM 

With   76   Illustrations 
Several  of  which  are   Printed  in   Colours 


PHILADELPHIA 

P.    BLAKISTON'S    SON    &    CO 
1012  WALNUT  STREET 
1909 


"K  D  ^'40 

1)3  + 


Copyright,  1908,  by  P.  Blakiston's  Son  &  Co. 


PRESS    OF 

WM.    P.    FElt    COMPANY 

1220-24    6AN80M    STREET 

PHILADELPHIA 


cn 


Gi 


TO  THE 
MEMORY  OF 

BILLROTH 
TERRIER 
MIKULICZ 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/surgeryofupperab01deav 


PREFACE. 


There  has  been  no  department  of  surgery  which  has  attracted 
more  attention,  in  recent  years,  than  the  surgery  of  the  upper  abdo- 
men. Numerous  monographs,  dealing  with  various  phases  of  the 
subject,  have  been  pubHshed  in  English,  in  French,  in  German,  and 
in  other  modern  languages.  It  seemed  to  the  authors  that  a  stage 
had  been  reached  when  it  would  not  be  without  value  to  review  this 
subject,  and  to  present  to  the  profession  the  results  of  their  studies, 
as  well  as  an  expression  of  opinion  based  on  these  studies  and  on  an 
experience,  which  has  not  been  very  limited,  with  the  treatment, 
operative  and  otherwise,  of  the  surgical  lesions  of  the  stomach, 
duodenum,  liver  and  bile  passages,  pancreas,  and  spleen. 

The  present  volume  comprises  the  surgery  of  the  stomach  and 
duodenum ;  and  it  is  hoped  that  the  publication  of  the  second  volume 
will  not  be  long  delayed. 

An  immense  mass  of  literature  has  accumulated  within  recent 
years  dealing  with  the  surgery  of  the  stomach;  and  to  consult  all 
of  this,  and  to  sift  the  valuable  from  the  worthless,  has  been  no  light 
task.  It  was  realized,  however,  that  opinions  based  on  personal 
work  alone  are  at  times  liable  to  bias;  and  it  has  therefore  been  the 
endeavour  of  the  authors,  while  always  stating  explicitly  their  own 
opinions  and  practices,  also  to  present  those  of  other  surgeons;  and 
to  express  their  own  adherence  to  or  dissent  from  those  views  and 
practices,  as  well  as  the  reasons  therefor,  with  candour  and  sincerity. 
It  has  not  been  deemed  advisable,  nor  would  it  have  been  possible 
in  a  work  of  this  size,  to  give  every  bibliographical  reference  con- 
sulted; but  there  has  been  appended  to  each  section  a  list  of  the  more 
important  references. 

The  descriptions  of  the  operations  employed  have  been  made  as 
concise  as  is  compatible  with  clearness.     An  endeavour  has  been  made, 


viii  Preface. 

and  the  authors  venture  to  hope  not  without  success,  to  include  a 
sufficient  number  of  cuts  fully  to  illustrate  the  text,  without  converting 
the  work  into  an  atlas.  The  illustrations,  whicli  ha\e  all  been  drawn 
expressly  for  this  volume  by  Mr.  Chas.  F.  Bauer,  maintain  the  high 
standard  of  beauty  and  of  accuracy  in  detail  for  which  his  work  is 
so  well  known.  INIany  of  them  are  original ;  others  have  been  redrawn, 
with  the  alterations  and  additions  which  have  suggested  themselves  to 
the  authors,  from  such  well  kno\\Ti  sources  as  Andrews,  Bardeleben, 
Bennett,  Caird,  Cautley  and  Dent,  Cuneo,  Guibe,  Mayo,  Mongour, 
Moynihan,  ]\Iusscr,  and  Sobotta. 

The  authors  have  to  thank  Dr.  A.  D.  Whiting  for  his  very  pains- 
taking and  accurate  work  in  tracing  the  patients  operated  on  at  the 
German  Hospital;  for  compiling  the  statistics  derived  from  these 
cases;  for  kindly  criticism  and  assistance  in  the  preparation  of  the 
text;  for  his  help  in  reading  the  proofs;  and  for  the  preparation  of 
the  index.  Their  thanks  are  due  to  Dr.  P.  G.  Skillern,  Jr.,  for  assis- 
tance in  the  preparation  of  the  chapters  on  Anatomy  and  Physiology. 
\\'ithout  the  help  thus  given,  more  than  the  four  years  already  passed 
would  have  been  consumed  in  the  preparation  of  the  volume. 

J.  B.  D. 

A.  P.  C.  A. 
December  i,  190S. 


TABLE  OF  CONTENTS. 


CHAPTER                                                   .  PAGE 

I.  Anatomy '. i 

II.  Physiology  of  Digestion 31 

III.  General  Diagnostic  Considerations 56 

IV.  Benign  Diseases  of  the  Stomach  and  Duodenum: 

Gastric  Ulcer 67 

V.  Benign  Diseases  of  the  Stomach  and  Duodenum  (Continued): 
Pyloric  Obstruction. 

Infantile  Stenosis  of  the  Pylorus 133 

Pylorospasm 143 

Acute  Dilatation  of  the  Stomach 146 

Atonic  Dilatation  of  the  Stomach 157 

Secondary  Gastric  Dilatation 161 

Gastroptosis 174 

VI.  Benign  Diseases  of  the  Stomach  and  Duodenum  (Continued): 
Obstruction  of  the  Cardiac  Orifice  of  the  Stomach. 

Congenital  Imperf oration  of  the  (Esophagus 179 

Cardiospasm 183 

Cicatricial  Contraction  of  the  Cardia 185 

VII.  Hour-glass  Stomach 186 

Gastric  Diverticula 198 

VIII.  Benign  Diseases  of  the  Duodenum: 

Duodenal  Ulcer 200 

Congenital  Imperf  oration  of  the  Duodenum 209 

Strictures  of  the  Duodenum 209 

Chronic  Dilatation  of  the  Duodenum 210 

Hour-glass  Duodenum 210 

Diverticula  of  the  Duodenum 211 

IX.  Benign  Tumors  of  the  Stomach  and  Duodenum 213 

Myoma  and  Fibro-myoma , 214 

Adenoma  and  Papilloma 221 

Lipoma 226 

Cysts 228 

Osteoma 232 

Concretions ; 232 

Angeioma 232 

Lymphadenoma 233 

Plastic  Linitis 234 


X  Table  of  Contents. 

CHAPTER  PAGE 

X.  Miscellaneous  Affections  of  the  Stomach  and  Duodenum: 

Tul  )erculosis 238 

Syphilis 245 

Phlegmonous  Gastritis 249 

Volvulus  of  the  Stomach 253 

Eventration  of  the  Diaphragm 257 

Diaphragmatic  Hernia 259 

XI.  Malignant  Diseases  of  the  Stomach: 

Carcinoma 268 

XII.  ^Slahgnant  Diseases  of  the  Stomach  and  Duodenum: 

Sarcoma  of  the  Stomach 303 

Carcinoma  of  the  Duodenum 307 

Sarcoma  of  the  Duodenum 308 

XIII.  Injuries  of  the  Diaphragm,  Stomach,  and  Duodenum: 

Injuries  of  the  Diaphragm 310 

Injuries  of  the  Stomach 315 

Injuries  of  the  Duodenum 337 

XIV.  Technicjue  of  Operations: 

Preparation  for  Operation 341 

Operative  Technique  in  General 342 

After-treatment 348 

Gastrotomy 351 

Gastrostomy 353 

Pyloroplasty 362 

Gastro-Duodenostomy 367 

Gastro-Jejunostomy 368 

Gastroplasty 386 

Gastro-Gastrostomy 387 

Gastro- Anastomosis 387 

Gastro-Phcation 388 

Gastropexy 388 

Gastrectomy 390 

Pylorectomy  (Billroth  I) 391 

Partial  Gastrectomy  (Kocher) 393 

Partial  Gastrectomy  (Billroth  II ) 396 

Cylindrical  Gastrectomy 403 

Gastric  Resection 404 

Jejunostomy 407 

XV.  Complications  and  Sequels: 

Causes  of  Death  after  Operation 411 

Vicious  Circle 4^9 

Peptic  Ulcer  of  Jejunum 431 

Internal  Hernia 435 

Gastric  Fistula 436 

Duoflenal  Fistula 44^ 

Subphrenic  Abscess 443 

Index  of  Namks  453 

Index 4^'  1 


LIST  OF  ILLUSTRATIONS. 


FIGURE  PAGE 

1 .  Diagram  of  Early  Stage  of  Developement 7 

2.  Diagram  Showing  Relation  of  Duodenum  to  Liver  and  Pancreas 8 

3.  Diagram  Representing  Early  Stage  of  Rotation  of  Abdominal  Viscera 9 

4.  Diagram  Representing  Later  Stage  of  Rotation  of  Abdominal  Viscera 10 

5.  Lymphatic  Areas  of  the  Stomach 13 

6.  Semi-diagrammatic  Drawing  of  the  Arteries,  Veins,  and  Lymphatics  of  the 

Stomach 14 

7.  Probe  in  Foramen  of  Winslow 15 

8.  Structures  in  the  Lesser  Peritoneal  Cavity  Exposed  by  Dividing  the  Gastro- 

colic Omentum 16 

9.  Sagittal  section  through  Upper  Abdomen,  Passing  through  Gall-bladder  and 

Descending  Duodenum, 18 

10.  The  Bile  Ducts  and  their  Relation  to  the  Duodenum  and  Pancreas 20 

11.  Interior   of   Stomach,  Pylorus,  and   Duodenum,  Showing   Papilla  of  Vater, 

also  Orifice  of  Duct  of  Santorini 21 

12.  The  Origin  of  the  Jejunum,  and  the   Duodeno-jejunal    Fossa,  Exposed  by 

Turning  the  Transverse  Colon  Upward 27 

13.  The  Pancreas,  its  Ducts,  and  their  Relation  to  the  Duodenum 29 

14.  Graphic  Representaion  of  the  Bacterial  Content  of  the  Gastro-intestinal  Tract  42 

15.  Diagram  to  Show  the  Relation  of  the  Lobes  of  the  Liver  to  A^arious  Abdomi- 

nal Structures,  Indicated  by  Blood  Currents  in  the  Portal  Vein 44 

16.  Diagram  Showing  Sites  of  Perforated  Gastric  Ulcers 84 

17.  Diagram  Showing  Sites  of  Perforated  Gastric  Ulcers 84 

18.  W.  J.  Taylor's  Specimen    Showing  Rupture  of  a  Varicose  Gastric  Vein  near 

the  Cardia 98 

19.  Infantile  Stenosis  of  the  Pylorus 136 

20.  Acute  Dilatation  of  the  Stomach 150 

21.  Perigastric  Adhesions,  Involving  Gall-bladder,  Colon,  and  Sigmoid    Flexure  164 

22.  Various  Degrees  of  Gastroptosis 174 

23.  Hour-glass  Stomach  from  Carcinomatous  "Saddle"  Ulcer  on  Lesser  Curva- 

ture with  Perforation 188 

24.  Hour-glass  Stomach  from  Perigastric  Adhesions 189 

25.  Fibroma  of  Posterior  Wall  of  Stomach 215 

26.  Polypus  of  Stomach  near  Pylorus 222 

27.  Gastric  Polypus  near  Pylorus,  Acting  as  Ball-valve 222 

28.  Total  Contraction  of  the  Stomach  from  Plastic  Linitis 235 

29.  Wiesinger's  Case  of  Volvulus  of  the  Stomach 254 

30.  Diagram  to  ShowOverlappingof  Anterior  Gastric  Wall  by  Surrounding  Struc- 

tures    316 

31.  Diagram  to  Show  Relations  of  Posterior  Gastric  Wall  to  Surrounding  Struc- 

tures    317 

32.  Diagram  made  by  Superimposing  Fig.  31  on  Fig.  30  to  Show  Close  Relations 

of  Stomach  to  Surrounding  Structures 317 

^^.  Wide  Opening  of  the  Gastro-colic  Omentum  to  Explore  Posterior    Gastric 

Wall 323 

34.  Czerny  and  Lembert  Sutures 344 

35.  Interrupted  Lembert  Suture 344 


xii  List  of  Illustrations. 

riGCRE  PAGE 

36.  Starting  Continuous  Lembert  Suture 344 

37.  Continuous  Lembert  Suture 345 

38.  Finishing  Continuous  Leml5erl  Suture 345 

39.  Starting  New  Lembert  Suture 345 

40.  Interrupted  Mattress  Suture 345 

41.  Continuous  ]Mattrcss  Suture 346 

42.  Right  Angled  Suture 346 

43.  Suture  of  Peritoneum 346 

44.  "  Splint  Sutures  " 347 

45.  Suture  of  Anterior  Sheath  of  Rectus 348 

46.  Tying  "  Splint  Sutures  " 349 

47.  Witzel's  Gastrostomy,  Suturing  the  Catheter  in  Place 354 

48.  Witzel's  Gastrostomy,  Closure  of  the  Abdominal  Wound 355 

49.  Finney's  Pyloroplasty,  First  Step 362 

50.  Finney's  Pyloroplasty,  Second  Step 363 

51.  Finney's  Pyloroplasty,  Third  Step 364 

52.  Finney's  Pyloroplasty,  Fourth  Step 365 

53.  Finney's  Pyloroplasty,  Fifth  Step 366 

54.  Finney's  Pyloroplasty,  Completed 367 

55.  Diagram  to  Show  Petersen's  Method  of  Gastro-jejunostomy 369 

56.  Anterior  Gastro-jejunostomy  with  the  Murphy  Button 372 

57.  Diagram  to  Show  Use  of  the  Elastic  Ligature  of  McGraw 375 

58.  Picking  up  the  Primary  Loop  of  the  Jejunum 376 

59.  Posterior  Gastro-jejunostomy  with  Entero-anastomosis 380 

60.  Posterior  Gastro-jejunostomy  with  no  Jejunal  Loop 382 

61.  Diagram  of  Incisions  for  (i)  Gastroplasty;  (2)  Gastro-anastomosis 386 

62.  Gastroplasty 386 

63.  Gastro-gastrostomy 387 

64.  Gastro-anastomosis 387 

65 .  Gastro-plication 388 

66.  Gastro-plication,  Seen  in  Sagittal  Section 388 

67.  Diagram  Showing  Various  Incisions  for  Gastrectomy 390 

68.  Partial  Gastrectomy:  Division  of  Gastro-colic  Omentum 397 

69.  Partial  Gastrectomy:    The  Duodenum  has  been  Divided,  and  the  Clam])s 

are  in  Place  for  the  Gastric  Section 398 

70.  Partial  Gastrectomy:    Through-and-through   Sutures    Being  Ajiplied    to  the 

Gastric  Section 399 

71.  Partial  Gastrectomy:  Sero-serous  Sutures  Being  Applied  to  the  Stomach 400 

72.  Portion  of  Carcinomatous  Stomach  Removed  by  Partial  Gastrectomy 402 

73.  Specimen  Shown  in  Fig.  72  Split  Open  Through  Pylorus 402 

74.  Jejunostomy  by  the  Method  of  Karewski 407 

75.  Jejunostomy  in  Y 408 

76.  Diagram  to  Show  Course  of  Gastric  and  Duodenal  Contents 420 


SURGERY  OF  THE  UPPER  ABDOMEN 


CHAPTER  I. 
ANATOMY. 

Systematic  descriptions  of  anatomy  are  sought  in  treatises  specially 
devoted  to  the  subject;  and  what  a  reader  desires  to  find  in  a  work 
like  the  present  is  the  surgical  or  applied  anatomy  of  the  parts  under 
discussion.  The  histological  structure  of  the  various  organs  is 
therefore  omitted,  together  with  a  detailed  statement  of  their  size, 
shape,  and  minute  relations  to  other  structures.  It  has  seemed  wise, 
moreover,  to  consider  the  subject  of  the  anatomy  of  the  upper  abdomen 
as  a  whole,  and  not  to  preface  the  surgery  of  each  organ  with  a  brief 
anatomical  outline  in  which  there  would  be  many  repetitions  required. 

The  Abdominal  Wall. — To  the  operating  surgeon  the  abdominal 
wall  should  present  itself  as  a  muscular  and  aponeurotic  structure 
whose  subsequent  strength  depends  upon  the  skill  and  judge- 
ment with  which  it  is  divided  and  sutured  during  an  operation. 
Transverse  division  of  the  muscular  fibres  is  to  be  studiously  avoided ; 
but  it  is  to  be  borne  in  mind  that  a  firmer  scar  usually  results  when 
longitudinal  separation  of  these  fibres  has  been  employed  than  when 
the  incision  has  been  made  through  aponeurotic  tissues  alone — such 
as  the  linea  alba  or  the  linea  semilunaris. 

The  rectus  muscle  is  attached  at  the  costal  margin  as  far  out- 
ward as  the  ninth  costal  cartilage,  and  this  is  therefore  the  limit 
of  longitudinal  incisions.  In  its  upper  two-thirds  the  rectus  muscle 
is  about  three  inches  broad,  being  somewhat  narrower  as  it  approaches 
the  pubic  spine.  In  the  cadaver  the  muscle  is  usually  less  broad  than 
during  life,  often  measuring  less  than  two  inches  in  width.  Outside 
of  the  semilunar  line  the  incision  should  be  transverse,  and  more  or 


2  Anatomy. 

less  oblique;  the  fibres  of  the  lateral  muscles  of  the  abdomen  do  not 
all  run  in  the  same  direction,  and  any  simple  incision  must  divide 
one  of  the  muscular  planes  obliquely.  But  oblique  or  even  transverse 
diA-ision  of  one  or  two  of  the  lateral  muscles  creates  by  no  means  so 
serious  a  wound  as  transverse  division  of  the  rectus  muscle,  since  there 
will  almost  invariably  be  at  least  one  muscular  plane  whose  fibres  are 
merely  separated  longitudinally,  and  this  plane  will  serve  as  a  splint 
and  support  for  the  others.  As  the  fibres  of  the  internal  oblique 
and  trans\-ersalis  run  very  nearly  parallel  to  each  other  in  the  upper 
abdominal  wall,  it  is  best  to  make  any  oblique  incision  in  their  course 
parallel  to  the  margin  of  the  ribs,  and  to  disregard  the  external  oblique, 
cutting  its  fibres  transversely,  as  they  run  nearly  at  right  angles  to 
those  of  the  deeper  muscles  in  this  situation. 

The  chief  artery  met  with  in  the  upper  abdominal  wall  is  the 
internal  mammary  or  some  of  its  terminal  branches.  It  runs  be- 
tween the  rectus  muscle  and  its  posterior  sheath,  and  the  larger 
branches  are  toward  the  middle  line  of  the  body.  The  lower  inter- 
costal nerves  run  forward  transversely  between  the  internal  oblique 
and  transversalis  muscles,  pierce  the  posterior  sheath  of  the  rectus 
muscle  (the  deep  lamella  of  the  aponeurosis  of  the  internal  oblique), 
and  enter  the  rectus  muscle  from  its  deep  surface.  They  may  be 
cut  by  an  incision  parallel  to  the  fibres  of  the  rectus,  and  loss  of 
contractility  and  even  atrophy  of  the  part  of  the  muscle  so  aftcctcd 
has  been  known  to  follow  such  injury;  Ijut  as  a  rule  no  impairment 
of  function  is  apparent,  and  even  if  such  a  result  should  occur,  the 
di.sability  in  the  epigastric  region  is  much  less  serious  than  in  the 
hypoga.stric. 

The  distribution  of  the  lower  intercostal  nerves  is  important  in 
connection  with  cutaneous  hyperiesthesia,  muscular  rigidity,  and 
referred  pain — all  conditions  frequently  encountered  in  abdominal 
affections.  The  sixth  and  se\'enlh  nerves  su])])ly  the  skin  in  llie  epi- 
gastric region  (the  "pit  of  the  stomach");  the  eighth  and  ninth,  tliat 
region  between  the  e])igastrium  and  the  umbilicus  (the  linea  transversa 
of  the  rectus  muscle);  and  the  tenth,  ihc  umbilical  area.  The  cuta- 
neous hypera,'slhesia,  referred  ])ain,  and  muscular  rigidity  of  abdominal 
di.seases,  are  due,  as  is  well  known,  to  the  overllow  of  the  stimulation 


Surface  Anatomy.  3 

received  by  the  cells  in  the  spinal  cord  from  the  diseased  area.  When 
the  stimulation  overflows  into  sensory  nerve  filaments,  cutaneous 
hyperaesthesia  and  pain  are  produced;  but  the  motor  nerves  are 
usually  affected  also,  and  hence  muscular  rigidity  of  the  overlying 
abdominal  wall  is  produced  (viscero-muscular  reflex  of  Mackenzie), 
by  the  same  mechanism  as  that  by  which,  as  was  long  ago  pointed  out 
by  Hilton,  an  inflamed  joint  is  held  rigid  by  its  enveloping  muscles. 
As  the  flat  muscles  of  the  abdominal  wall  are  not  innervated  by  a 
single  nerve  trunk,  but  by  numerous  twigs  from  different  nerve  trunks, 
where  the  viscero-muscular  reflex  is  referred  along  one  trunk  only, 
merely  a  portion  of  the  muscle  will  contract.  This  is  not  so  im- 
portant in  the  upper  abdomen  as  in  the  ihac  region,  where  such  band- 
like rigidity  has  been  mistaken  for  a  palpably  enlarged  appendix. 

The  pain  referred  to  the  left  shoulder  blade  in  disease  of  the  duo- 
denum and  stomach  is  thus  to  be  explained  by  the  connection  between 
the  pneumogastric  nerves  and  the  sympathetic  ganglia  on  the  left  side. 
Mayo  Robson  and  Moynihan  have  pointed  out  that  as  long  as  the 
gall  bladder  only  is  involved,  the  referred  pain  is  felt  in  the  right  in- 
frascapular  region,  but  as  soon  as  the  inflammation  or  adhesions 
involve  the  pylorus,  the  pain  is  felt  also  in  the  left  infrascapular 
region. 

Running  from  the  umbilicus  upward,  along  the  deep  surface  of 
the  right  rectus  muscle,  to  the  longitudinal  fissure  of  the  liver,  is  the 
falciform  or  suspensory  ligament  of  this  organ,  containing  between  its 
layers  the  round  ligament  or  obhterated  umbihcal  vein  of  the  foetus; 
as  well  as  some  small  veins  from  the  epigastric  vein,  anastomosing 
with  the  portal  system ;  some  arterial  twigs  from  the  phrenic  arteries ; 
besides  lymphatics  and  nerves.  It  is  advisable,  therefore,  to  avoid 
division  of  this  fold  of  peritoneum  when  making  incisions  through  the 
abdominal  wall.  The  suspensory  ligament  lies  close  to  the  linea  alba, 
and  hence  an  incision  through  the  outer  half  of  the  right  rectus  muscle 
will  not  injure  it;  but  if  an  incision  in  the  linea  alba  is  to  be  extended 
past  the  umbilicus,  care  should  always  be  taken  to  make  the  cut 
around  the  left  margin  of  the  navel. 

Surface  Anatomy. — The  umbilicus  is  at  the  level  of  the  third 
lumbar  vertebra.     Approximately  between  it  and  the  spinal  column 


4  Anatomy. 

lies  the  third  or  transverse  portion  of  the  duodenum.  Above  the 
umbilicus  lies  the  transverse  colon,  about  three  lingerbreadths  vi^ide, 
and  between  this  and  the  ensiform  cartilage  are  found  the  pyloric 
portion  of  the  stomach,  and,  overlapping  this,  the  left  lobe  of  the  liver. 
The  longitudinal  fissure  of  the  liver,  separating  the  left  from  the  right 
lobe,  is  less  than  an  inch  to  the  right  of  the  median  line  of  the  body. 
If  the  transverse  colon  sag,  and  hang  below  the  umbilicus,  some 
coils  of  small  intestine  may  present  themselves  between  the  colon  and 
the  stomach,  displacing  the  transverse  mesocolon,  which,  as  well  as 
the  gastro-colic  omentum,  will  be  found  interposed  between  these 
displaced  intestines  and  the  anterior  abdominal  wall. 

The  central  tendon  of  the  diaphragm  is  found  at  the  base  of  the 
ensiform  process  of  the  sternum,  at  the  level  of  the  cartilage  of  the 
sixth  or  seventh  rib,  and  opposite  the  eighth  dorsal  vertebra.  The 
lateral  arches  of  the  diaphragm  rise  and  fall  slightly  during  respiration, 
the  right  being  shghtly  higher  than  the  central  tendon,  and  about 
three-cjuarters  of  an  inch  higher  than  the  left  arch. 

The  liver  fills  the  right  hypochondriac  region,  and  extends  through 
the  epigastrium  to  the  left  hypochondriac  region  to  a  distance  of  from 
one  to  two  and  a  half  inches  beyond  the  left  border  of  the  sternum. 
It  may  reach  the  left  mammary  line.  The  fiver  extends  as  high  as  a 
transverse  line  drawn  through  the  lower  end  of  the  gladiolus  (the 
mesosternum),  or  the  base  of  the  ensiform  cartilage.  The  upper 
surface  of  the  left  lobe  is  on  this  same  level  (the  fifth  intercostal  space) ; 
but  the  right  lobe  is  a  trifle  higher  and  is  said  to  reach  the  lower  border 
of  the  fifth  rib.  Since  the  position  of  the  liver  varies  slightly  with  that 
of  the  body,  and  with  the  movements  of  the  diaphragm,  these  outHnes 
are  only  approximately  correct.  The  lower  surface  of  the  right  lobe 
of  the  liver  posteriorly  is  opposite  the  spine  of  the  eleventh  dorsal 
vertebra,  and  in  the  midaxillary  line  is  at  the  costal  margin;  between 
the  miflaxillary  fine  and  the  right  semilunar  fine  the  thin  anterior 
margin  of  the  liver  projects  about  one-half  of  an  inch  below  the  costal 
margin,  and  crosses  the  median  line  of  the  body  in  a  line  drawn  from 
the  ninth  right,  to  the  eightli  left,  costal  cartilage.  The  gall  bladder 
lies  beneath  the  ninth  right  costal  cartilage  in  the  semilunar  line,  at 
the  outer  border  of  the  right  rectus  muscle. 


Surface  Anatomy.  5 

The  relations  of  the  stomach  vary  more  than  those  of  the  hver. 
When  distended,  it  is  in  contact  with  the  anterior  abdominal  wall  in  a 
triangle  bounded  by  the  anterior  margin  of  the  liver,  the  left  ninth 
and  tenth  costal  cartilages,  and  a  line  drawn  between  the  tenth  costal 
cartilages.  The  cardiac  orifice  of  the  stomach  is  opposite  a  point  one 
inch  to  the  left  of  the  seventh  left  chondro-sternal  junction,  at  the 
level  of  the  eleventh  thoracic  vertebra;  the  pyloric  orifice  lies  beneath 
the  liver,  about  three  inches  below  the  base  of  the  ensiform  cartilage, 
at  the  level  of  the  upper  edge  of  the  first  lumbar  vertebra;  but  as  the 
stomach  becomes  distended  the  pylorus  approaches  the  right  linea 
semilunaris.  The  line  for  the  lesser  curvature  of  the  stomach  is 
drawn  from  the  position  of  the  cardiac  orifice  to  that  of  the  pylorus. 
The  line  for  the  greater  curvature  extends  upward  and  to  the  left  from 
the  position  of  the  cardiac  orifice  to  the  fifth  rib,  slightly  external  to 
the  left  mammary  line,  and  thence  to  the  position  of  the  pyloric  orifice . 
The  line  of  the  greater  curvature  is  convex  downward  and  to  the  left ; 
that  of  the  lesser  curvature  is  nearly  vertical  when  the  stomach  is 
empty. 

The  duodenum  is  from  ten  to  twelve  inches  in  length,  commencing 
at  the  pyloric  orifice  of  the  stomach,  and  ending  in  the  jejunum  at  the 
left  side  of  the  body  of  the  second  lumbar  vertebra,  after  having 
described  a  half  circle  with  its  convexity  downward.  The  first 
portion  of  the  duodenum,  about  two  inches  long,  passes  from  the 
pyloric  end  of  the  stomach  to  the  right,  upward  and  backward,  to  the 
neck  of  the  gall  bladder;  the  second  portion  is  about  three  inches  in 
length,  and  extends  from  the  neck  of  the  gall  bladder,  downward 
along  the  right  of  the  spinal  column  to  the  level  of  the  third  lumbar 
vertebra.  Here  the  third  portion  of  the  duodenum  commences, 
passing  obliquely  upward  to  the  left,  across  the  body  of  the  second 
lumbar  vertebra.  A  line  drawn  from  a  point  three  inches  to  the  right 
of  the  umbilicus,  to  a  point  two  inches  to  the  left  and  above  it,  will, 
according  to  Shield,  nearly  indicate  the  position  of  the  third  portion. 
The  fourth  portion  is  only  about  an  inch  in  length ;  it  passes  upward 
from  the  termination  of  the  third  portion,  and  becomes  continuous 
with  the  jejunum  at  the  origin  of  the  mesentery. 

The  pancreas  extends  across  the  bodies  of  the  first  and  second 


6  Anatomy. 

lumbar  vertebrae  from  the  hilum  of  the  spleen  in  the  left  hypochondriac 
region,  to  the  second  portion  of  the  duodenum  in  the  epigastric  region. 
Its  length  is  from  six  to  eight  inches,  and  its  largest  portion,  called  the 
head,  is  surrounded  by  the  semicircle  of  the  duodenum  as  a  picture  is 
surrounded  by  its  frame;  while  its  body  crosses  the  spinal  column, 
and  its  tail  is  in  contact  with  the  spleen.  It  lies  between  the  coeliac 
axis,  above,  and  the  superior  mesenteric  vessels,  below,  these  latter 
separating  it  from  the  transverse  (third)  portion  of  the  duodenum. 

Embryology. — To  understand  the  various  folds  and  recesses  of 
the  peritoneum  in  the  upper  abdomen  it  is  essential  to  revert  to  the 
embryonal  stage  before  this  membrane  has  developed  the  perplexing 
conditions  found  in  adult  life.  For  practical  purposes  it  is  sufficient  to 
describe  the  foetal  state  as  follows :  The  peritoneum  is  to  be  regarded 
as  a  closed  sac  lilling  the  abdominal  cavity;  along  the  posterior  part 
of  the  abdominal  ca\'ity,  back  of  this  closed  sac  and  parallel  with  the 
spinal  column,  runs  the  digestive  tract  in  the  form  of  a  long  straight 
tube.  At  first  this  tube  is  in  connection  with  the  region  outside  of  the 
abdominal  cavity  by  means  of  a  prolongation  through  the  navel, 
known  as  the  vitelline  duct.  This  duct  later  becomes  detached  from 
the  navel,  but  is  sometimes  still  evident  in  adult  life  as  Meckel's 
diverticulum.  While  still  attached  to  the  umbilicus  it  acts  as  a  guy 
rope,  and  pulls  the  formerly  straight  intestinal  canal  forward  in  a 
U-shaped  projection,  the  arms  of  the  U  being  known  as  the  upper  and 
lower.  When  the  intestinal  tube  is  thus  pulled  forward,  the  closed 
peritoneal  sac  is  pushed  in  front  of  it  by  the  intestine,  which  becomes 
more  or  less  completely  covered  by  the  i)eritoneum,  still  retaining, 
however,  'an  extraperitoneal  surface  through  which  it  receives  its 
blood  vessels,  nerves  and  lymphatics.  The  two  folds  of  peritoneum 
covering  these  structures,  as  they  pass  to  the  intestinal  tube,  are  known 
as  the  mesentery.  The  upper  part  of  the  primitive  intestinal  tube, 
close  beneath  the  diaphragm,  becomes  dilated,  and  forms  the  stomach; 
at  first  it  lies  longitudinally  in  the  abdominal  cavity,  and  somewhat 
resembles  the  bulb  c)f  a  hand  s\ringc  in  its  relation  to  the  rest  of  the 
tube.  Its  greater  curvature  lies  ])()sterior,  and  the  pylorus  is  its 
lowest  part.  That  portion  of  the  jjrimitive  intestinal  tube  just  below 
the  stomach  forms  the  duodenum,  and  from  its  anterior  wall  the  liver 


Embryology. 


7 


grows  out,  as  a  compound  tubular  gland.  The  rapid  growth  of  the 
liver,  and  its  position  close  beneath  the  diaphragm,  account  in  large 
measure  for  the  peculiar  distributions  of  the  peritoneum  around  it. 


Stomach 


Duodenum 
Umbilical 

Falclform-H 

Mntesfine. 

Omphalo-Mii 
enteric  duct. 

llrachas. 

Hypogastric  Art. 


Caecum 


Hadder 


ectum 


Fig.  I. — Diagram  of  Early  Stage  of  Developement. 

The  portions  of  the  parietal  peritoneum  not  drawn  away  from  the  body  walls  to  form 

mesenteries,  ligaments,  etc.,  are  indicated  by  deeper  shading. 


It  developes  from  the  anterior  surface  of  the  duodenum,  and  grows 
forward,  pushing  the  peritoneum  in  front  of  it  and  downward,  leaving 
a  pedicle  of  peritoneum  only  at  its  origin  from  the  duodenum  and 


Anatomy. 


Post. Wall 


dorsal 
Mesentery 


/'an  ere  as 


Duodenu.ni 


along  its  inferior  surface,  lying,  so  to  speak,  above  the  closed  peritoneal 
sac,  between  this  membrane  and  the  diaphragm.  From  the  umbilicus 
there  passes  upward  outside  the  anterior  wall  of  the  closed  peritoneal 
sac,  a  vein,  known  as  the  umbilical  vein,  which  persists  in  the  adult  as 
the  round  ligament  of  the  liver,  and  which  is  enveloped  by  two  folds 
of  peritoneum  known  as  the  falciform  or  suspensory  ligament  of  the 
liver.  The  urachus  and  the  hypogastric  arteries  raise  similar  folds  of 
peritoneum  below  the  umbilicus.  The  round  ligament  passes  to  the 
longitudinal  fissure  of  the  liver,  and  when  it  reaches  the  transverse 

fissure  blends  with  the  portal 
vein,  into  which  vessel  it  emptied 
its  blood  during  intrauterine  life. 
The  duodenum  at  this  period 
of  developement  has  already  a 
mesentery  of  its  own,  slight  in 
extent,  lying  between  it  and  the 
posterior  abdominal  wall,  and 
of  course  continuous  above  with 
the  gastric  mesentery  and  below 
with  that  of  the  jejunum.  Into 
the  layers  of  this  duodenal 
mesentery  the  pancreas  growls, 
extending  backward  from  the 
duodenum,  just  as  the  liver 
grows  forward.  Now  com- 
mences a  com])lcx  ])rocess  of 
rotation  of  all  the  abdominal 
viscera.  The  lower  limb  of 
the  U  shaped  intestinal  lube,  in  which  the  ciecum  begins  to  bud, 
rotates  upward  in  front  of  and  above  the  upj)er  limb,  and  tlie 
Ciccal  portion  passes  first  through  the  um!)ilical  region  to  the  left 
hypochondriac  region,  thence  to  the  right  hy])ochondrium,  and  fmallv 
at  birth  settles  down  toward  the  right  iliac  region  of  the  abdomen. 
This  rotation  of  the  intestine  takes  ])lace  from  left  to  right  around  the 
superior  mesenteric  artery  as  an  axis  in  such  a  manner  that  the  colon 
crosses  the  commencement  of  the  small  intestine  transversely.     While 


Rkiform. 
AntWall 


Fig.  2. — Diagram  Showing  Relation  of 
Duodenum  to  Liver  and  Pancreas. 


Embryology.  9 

in  this  way  the  commencement  of  the  large  intestine  is  thrown  over  to 
the  right  side,  the  small  intestine  for  the  greater  part  assumes  a  posi- 
tion on  the  left,  and  the  former  right  side  of  the  mesentery  becomes  the 


Sup.Mesenteric  Art. 


Aorta 


Coeliac  Axis 


Bile  Duct. 


Duodenum, 


Pancreas 


Caecum 


S.Intestines 


£.  Intestine 


Fig.  3. — Diagram  Representing  Early  Stage  of  Rotation  of  Abdominal 

Viscera. 


left  and  vice  versa.  Thus,  the  lower  part  of  the  duodenum  is  carried 
to  the  left  and  the  commencement  of  the  large  intestine  is  carried  across 
it — an  explanation  of  the  position  of  the  duodenum  behind  the  trans- 


10 


Anatomy. 


verse  colon  in  the  adult,  and  of  the  passage  of  the  superior  mesenteric 
artery  over  the  front  of  the  duodenum.  The  influence  that  the  rota- 
tion of  the  intestinal  loop  has  upon  the  mesentery  may  be  readily 
appreciated:   the  attachment  of  the  mesentery  of  the  small  intestine 


StOf?iac/i 


Caecum 


Sup. 

Mesenteric 

'L-Art. 


L  Intestine 


S  Intestines 


Fir,.    4. — DiAC.RAM     Kl-.PKKSKNTIXG    LaTKR    StAGK   OK    ROTATION   OF    ABDOMINAL 

Viscera. 


(the  upjjer  liml)  of  the  U  slia])ed  (h'geslixc'  tube)  rrniains  ])raclically 
unchanged,  while  that  of  the  large  intestine  assumes  attachments  cor- 
responding to  the  ascending,  the  transverse  and  the  descending  meso- 
colon. At  the  same  lime  that  this  intestinal  rotation  is  taking  place 
from  left  to  right,  the  stomach  likewise  undergoes  rotation  in  the  same 


Embryology.  Ii 

direction,  so  that  its  left  side  becomes  anterior,  and  its  right  side 
posterior  in  position.  The  liver  passes  to  the  right  hypochondriac 
region,  and  the  pancreas  is  shifted  posteriorly  and  slightly  to  the  left. 
The  pyloric  end  of  the  stomach  ascends,  and  the  greater  curvature 
becomes  the  inferior  border,  while  the  lesser  curvature  becomes  the 
superior  border  of  the  stomach.  The  stomach  has  now  therefore  an 
anterior  and  a  posterior  wah,  both  covered  with  peritoneum;  but 
whereas  the  anterior  is  in  free  communication  with  the  general  cavity 
of  the  peritoneum,  the  posterior  wall  has  become  more  or  less  isolated, 
and  is  in  relation  with  the  pancreas,  the  lesser  peritoneal  cavity  separat- 
ing them.  This  lesser  peritoneal  cavity  retains  its  only  connection 
with  the  general  peritoneal  cavity  at  its  right  extremity  through  the 
foramen  of  Winslow.  Above  the  stomach  the  gastro-hepatic  omentum 
stretches  from  its  lesser  curvature  to  the  liver,  while  from  its  greater 
curvature  the  great  omentum  passes  downward  between  the  stomach 
and  the  transverse  colon,  at  first  consisting  of  two  double  folds  of 
peritoneum.  Later  these  double  folds  fuse  and  become  adherent 
to  the  transverse  colon,  so  that  the  adult  type  is  found  shortly  after 
birth.  The  duodenum  and  the  pancreas  are  by  this  process  of 
rotation  sequestrated  behind  the  stomach  and  transverse  colon, 
and  being  subject  to  no  movement  of  any  consequence  lose  their 
posterior  mesenteries  by  absorption,  and  become  in  extrauterine 
life  retroperitoneal  organs.  It  is  a  law  that  when  two  serous 
surfaces  are  approximated,  and  little  or  no  motion  exists  between 
them,  they  fuse.  Thus,  the  duodenum  and  its  mesentery,  in 
which  the  outgrowth  of  the  pancreas  developes,  are  pressed  by  the 
transverse  colon  against  the  posterior  abdominal  wall,  and  unite 
extensively  with  the  peritoneum  covering  the  latter.  Growing  apace 
with  the  gut  at  its  intestinal  attachment,  the  mesentery  of  the  small 
intestine  is  thrown  into  fan-shaped  folds,  since  at  its  vertebral  attach- 
ment it  remains  short.  Carried  by  the  colon  transversely  across  the 
end  of  the  duodenum,  the  transverse  mesocolon  obtains  secondary 
attachment  to  the  latter  and  to  the  posterior  abdominal  wall,  in  a  hne 
from  left  to  right,  and  remains  permanently  as  a  well-marked  mesen- 
tery. Thus,  the  transverse  colon  with  its  mesocolon  divides  the  ab- 
dominal cavity  into  an  upper  part  that  includes  stomach,  liver,  duo- 


12  Anatomy. 

denum  and  pancreas,  and  a  lower  which  contains  the  small  intestine. 
The  mesenteries  of  the  ascending  and  descending  colon  become  ob- 
literated by  fusing  with  the  parietal  peritoneum  of  the  posterior  ab- 
dominal wall,  so  that  in  the  mature  condition  these  parts  of  the  gut  are, 
as  a  rule,  covered  by  peritoneum  only  in  front  and  at  the  sides. 

The  developement  of  the  great  omentum  begins  in  the  third  month. 
Starting  at  the  greater  curvature  of  the  stomach,  it  extends  gradually 
downward,  thus  overlying  in  the  first  instance  the  transverse  colon, 
and  then  the  small  intestine.  Coming  in  contact  in  the  first  part  of 
its  course  with  the  transverse  mesocolon  the  great  omentum  soon 
fuses  with  this  and  with  the  transverse  colon,  and  this  relation  be- 
comes permanent.  The  pancreas,  at  first  situated  between  the  two 
layers  of  the  mesogastrium,  now  accjuires  its  retroperitoneal  position. 

Topographical  Anatomy. — Stomach. — In  adult  fife  the  stomach 
is  almost  entirely  intraperitoneal.  It  retains  its  primitive  mesentery 
from  its  greater  curvature  in  the  form  of  the  gastro-colic  omentum; 
while  the  mesentery  acquired  for  it  by  the  growth  of  the  liver,  at- 
tached to  the  lesser  curvature,  is  known  as  the  gastro-hepatic  omentum. 
The  greater  and  lesser  curvatures  of  the  stomach  are  thus  extraperi- 
toneal, and  contain  the  main  blood  vessels.  Along  the  lesser  curvature 
run  from  left  to  right  the  gastric  or  coronary  artery,  from  the  coeliac 
axis,  and  from  right  to  left  the  pyloric  artery,  from  the  hepatic  artery, 
itself  a  branch  of  the  coeliac  axis.  Along  the  greater  curvature  of  the 
stomach  runs  from  left  to  right  the  gastro-epiploica  sinistra,  from  the 
splenic,  and  from  right  to  left  the  gastro-epiploica  dextra,  from  the 
hepatic  through  the  gastro-duodenal.  The  anastomosis  of  both 
pairs  of  arteries  is  \'ery  free,  and  when  divided  at  any  part  of 
their  course  severe  hemorrhage  from  both  ends  is  to  be  antici- 
pated. Smaller  branches  are  given  off  at  right  angles,  which  run 
trans\'ersely  across  the  walls  of  llic  slomacli.  The  l)ran(hcs  from  tlie 
lesser  curvature  supply  aljout  two-thirds  of  the  areas  on  the  anterior 
and  posterior  gastric  walls.  The  veins  correspond  to  the  arteries,  and 
ultimately  empty  into  the  portal  vein. 

Except  for  these  omental  regions  the  only  extraperitoneal  portion 
of  the  stomach  is  a  small  and  irregular  triangular  area  on  its  posterior 
surface  near  the  cardiac  opening.     One  angle  of  this  triangle  is  at  tlie 


Topographical  Anatomy. 


13 


point  where  the  coronary  artery  reaches  the  stomach  (the  gastro- 
phrenic hgament),  a  second  is  at  the  commencement  of  the  gastro- 
splenic  portion  of  the  great  omentum,  while  the  third  is  to  the  left  of 
and  below  the  cardiac  opening  of  the  stomach. 

The  lymphatics  of  the  stomach  are  of  considerable  importance  in 
connection  with  the  metastasis  of  malignant  growths,  and  have  only 
within  recent  years  received  adequate  attention.  As  pointed  out  by 
Cuneo,  who  has  studied  the  spread  of  malignant  gastric  neoplasms 
along  the  lymphatics,  the  stomach  may  be  divided  roughly  into  three 
lymphatic  areas:  one,  in  the  region  of  the  fundus  of  the  stomach, 
where  the  nodes  are  few,  and  two  others,  along  the  greater  and  lesser 
curvatures  respectively.  Of  these  latter  two  areas,  the  nodes  along 
the  lesser  curvature  are  much  more 
apt  to  be  involved  in  malignant 
growths,  the  area  alTected  extending 
as  far  toward  the  oesophageal  end 
of  the  stomach  as  the  position  of  the 
coronary  artery;  while  the  duodenum 
is  rarely  involved  (Carle  and  Fantino) 
for  a  distance  of  more  than  two  or 
three  centimetres.  The  nodes  along 
the  greater  curvature  do  not  enlarge 
so  soon  as  do  those  along  the  lesser. 
The  practical  deductions  from  these 

facts  will  be  considered  in  greater  detail  when  discussing  malignant 
growths  of  the  stomach.  From  these  various  lymphatic  nodes  the 
lymph  vessels  pass  to  the  coeliac  nodes;  the  vessels  from  the  lesser 
curvature  following  the  course  of  the  coronary  artery,  and  those  from 
the  greater  curvature  running  with  the  right  gastro-epiploic  vessels, 
both  sets  eventually  meeting  in  the  same  nodes  (coeliac)  around  the 
aorta,  above  the  origin  of  the  superior  mesenteric  artery.  Jamieson 
and  Dobson  have  recently  made  a  study  of  the  lymphatics  of  the 
stomach.  They  found  nodes  beneath  the  pylorus  quite  frequently 
present,  draining  the  neighbouring  portion  of  the  greater  curvature. 
In  not  a  few  instances  they  were  able  to  trace  lymph  channels  from 
the  pylorus  directly  past  the  lower  coronary  group  of  glands  into  the 


Fig.  5. — Lymphatic  Areas  of  the 
Stomach. 


14 


Anato 


my. 


right  suprapancrcatic  glands  lying  along  the  trunk  of  the  hepatic 
artery. 

The  stomach  is  supplied  hberally  by  sympathetic  nerves,  as  well  as 
by  the  terminal  filaments  of  the  pneumogastric.  The  left  pneumo- 
gastric  curves  around  to  the  anterior  border  of  the  oesophagus,  just 
above  the  cardiac  orifice  of  the  stomach,  and  distributes  branches  to 
the  lesser  curvature  and  anterior  wall  of  the  stomach;  while  the  right 
pneumogastric  is  similarly  distributed  over  the  posterior  wall.     Fila- 


FlG.    6. — SEMI-qiAGRAMMATIC  DRAWING   OF   THE   .A.RTEKIES,    \'EINS,    AND   LYMPHATICS 

OF  THE  Stomach. 


ments  from  both  nerves  inosculate  along  the  greater  curvature.  Some 
filaments  from  the  right  nerve  pass  to  the  left  side  of  the  coeliac  and 
splenic  plexuses  of  the  sympathetic  system,  while  some  of  the  filaments 
from  the  left  nerve  pass  from  the  lesser  curvature  of  the  stomach 
through  the  gastro-hepatic  omentum  to  the  hepatic  plexus.  The 
free  nerve  supply  of  the  stomach  is  largely  rcs])()nsible  for  the  great 
pain  experienced  in  ulcerations  and  adhesions  of  this  viscus. 

The  posterior  wall  of  the  stomach  cannot  be  satisfactorily  i)a]|)ated 


Topographical  Anatomy. 


15 


through  the  foramen  of  Winslow;  as  a  rule  only  the  posterior  surface 
of  the  pylorus  is  thus  reached.  In  the  free  fold  of  the  gastro-hepatic 
omentum  may  be  felt  the  common  bile  duct,  furthest  forward,  and 
further  in  and  to  the  patient's  left  the  hepatic  artery,  with  the  portal 
vein  behind  and  between.  The  duct  of  Wirsung  (pancreatic)  is  too 
short  and  too  low  down  to  be  palpated  without  loosening  the  layer  of 


Fig.  7. — Probe  in  Foramen  of  Winslow. 
The  liver  has  been  drawn  upward  to  expose  the  gastro-hepatic  omentum. 


peritoneum  covering  the  right  side  of  the  descending  duodenum.  To 
expose  thoroughly  the  posterior  wall  of  the  stomach  we  have  a  choice 
of  two  routes — through  the  gastro-colic  omentum,  or  through  the  trans- 
verse mesocolon.  As  a  rule  the  latter  is  to  be  preferred,  because  it  is 
in  most  cases  the  proper  route  for  the  performance  of  gastro-jejun- 
ostomy,  but  because  the  gastro-colic  omentum  may  be  more  widely 


i6 


Anatomy. 


opened  this  is  the  route  to  be  selected  in  emergencies.  The  incision 
in  the  transverse  mesocolon  should  be  antero-posterior,  so  as  to  avoid 
the  middle  colic  artery  and  its  branches.  Where,  however,  it  is 
merely  desired  to  explore  the  posterior  wall  of  the  stomach,  gastro- 
enterostomy not  being  contemplated,  and  where  the  gastro-colic 
omentum  is  sufficiently  wide  to  permit,  this  may  be  divided,  close  to 


Fig.  8. — Stkuctukks  i.n  thk  Lesser  Peritoneal  Cavity  Exposed  by  Dividing  the 
Gastro-coijc  Omentum. 


the  colon,  so  as  to  avoid  the  gaslro  epiploic  arteries,  and  the  stomach 
partially  inverted  through  the  opening. 

The  cardiac  orifice  of  the  stomach  is  directed  almost  horizontally, 
so  that  the  surgeon's  finger,  seeking  entrance  to  the  cEsophagus  from 
within  the  stomach  must  be  passed  toward  the  ])atient's  right.  The 
Vjody  of  the  stf)mach  is  divided  into  the  fun(kis  and  the  ])yloric  antrum 
by  a  sphincter-like  band  of  muscle  (sphincter  of  the  antrum  pylori) 


Topographical  Anatomy.  17 

which  encircles  the  stomach  at  a  variable  distance  from  the  pylorus. 
A  line  dropped  vertically  from  the  cardiac  orifice  will  usually  represent 
the  approximate  position  of  this  sphincter.  The  musculature  of  the 
pyloric  antrum  is  much  more  developed  than  is  that  of  the  fundus  of 
the  stomach,  a  fact  which  is  explained  by  the  motor  functions  of  the 
stomach  during  digestion  (p.  47).  When  tonic  contraction  of  the 
pyloric  antrum  exists,  the  surgeon  may  be  deceived  at  operation  into 
thinking  the  case  one  of  hour  glass  stomach,  so  distorted  does  the 
outhne  of  the  stomach  appear. 

Liver. — The  liver  presents  several  extraperitoneal  areas.  The 
largest  is  on  the  postero-superior  surface  of  the  right  lobe,  between  the 
layers  of  the  right  portion  of  the  coronary  ligament.  Here,  about  the 
middle  of  the  posterior  surface  of  the  liver,  the  inferior  vena  cava  is 
found.  The  extraperitoneal  area  between  the  layers  of  the  median 
and  left  portions  of  the  coronary  ligament  is  insignificant  in  size,  as  is 
also  that  region  about  the  transverse  fissure  where  the  bile  duct,  the 
portal  vein  and  the  hepatic  artery  are  found.  For  practical  purposes, 
therefore,  the  liver  is  wholly  an  intraperitoneal  organ;  although  ab- 
scesses pointing  through  its  superior  surface  are  usually  excluded  from 
the  general  peritoneal  cavity  by  adhesions. 

When  the  hand  is  introduced  between  the  right  lobe  of  the  liver 
and  the  diaphragm  through  an  abdominal  incision,  it  passes  back- 
ward over  the  upper  convex  surface  of  the  liver  for  about  six  inches, 
when  the  finger  tips  are  arrested  by  the  coronary  ligament,  running 
transversely  across  the  surface  of  the  liver.  The  falciform  ligament 
will  be  felt  running  forward  from  the  coronary  ligament,  close  to  the 
median  line  of  the  body,  and  will  prevent  the  fingers  from  passing 
from  the  surface  of  the  right  lobe  across  to  that  of  the  left.  By  carry- 
ing the  hand  well  along  to  the  right  edge  of  the  liver,  the  right  ex- 
tremity of  the  coronary  ligament,  known  as  the  right  lateral  ligament, 
will  be  felt,  and  in  some  cases  the  fingers  can  be  passed  around  the 
free  margin  of  this  ligament  on  to  the  posterior  surface  of  the  liver, 
back  of  the  posterior  layer  of  the  coronary  ligament.  The  hand  is 
here  arrested  by  the  reflection  of  the  visceral  peritoneum  on  to  the 
posterior  abdominal  parietes.  On  the  left  side  of  the  falciform  liga- 
ment, above  the  left  lobe  of  the  liver,  the  left  coronary  ligament,  and 


1 8  Anatomy. 

its  extreme  portion,  the  left  lateral  ligament,  may  likewise  be  palpated 
by  the  examining  hand. 

The  under  surface  of  the  liver  is  also  quite  easily  examined  by  the 


[IfANl^trt  I'   irJl^^l    ^ 


Fig.  9.— Sagittal  Skctio.m  thkough  Upper  Abdomkn,  Passing  through  Gall- 
Bi^ADDER  and  Descending  Duodenum.  To  show  Reflection  of  Peritoneum. 
— (After  Bardelcben.) 


sense  of  touch.  At  the  cartilage  of  the  right  ninth  rib,  a  couple  of 
inches  to  the  right  of  the  falciform  ligament,  held  close  against  the 
under  surface  of  the  liver  by  a  fold  of  peritoneum,  is  the  gall-bladder. 


Topographical  Anatomy.  19 

and  by  following  this  landmark  backward  with  the  fingers,  we  are 
led  first  to  the  cystic  duct,  then  across  the  anterior  margin  of  the 
foramen  of  Winslow  along  the  common  bile  duct  in  the  free  margin  of 
the  gastro-hepatic  omentum,  to  the  posterior  surface  of  the  pylorus. 
Beyond  this  point  the  duct  usually  cannot  be  palpated,  as  it  becomes 
retroperitoneal  behind  the  descending  part  of  the  duodenum.  To 
the  right  of  the  gall  bladder  the  hand  will  pass  beneath  the  right 
lobe  of  the  liver  and  above  the  transverse  mesocolon  and  the  upper 
pole  of  the  right  kidney,  as  far  as  the  posterior  abdominal  wall  (twelfth 
rib) ;  and  in  some  cases  slightly  upward  on  the  posterior  surface  of  the 
liver,  before  meeting  with  the  inferior  reflection  of  peritoneum  which 
forms  the  posterior  layer  of  the  right  coronary  ligament.  Close  to  the 
spinal  column  the  ascending  vena  cava  can  be  palpated.  Passing  the 
hand  to  the  left  of  the  gall  bladder,  along  the  inferior  surface  of  the 
left  lobe  of  the  liver,  the  fingers  are  arrested  within  a  few  inches  by  the 
attachment  of  the  gastro-hepatic  omentum  along  the  transverse  fissure 
of  the  liver.  This  fissure  is  limited  on  the  right  by  the  neck  of  the 
gall  bladder  and  the  cystic  duct,  and  on  the  left  by  the  round  ligament 
within  the  folds  of  the  falciform  ligament  attached  to  the  longitudinal 
fissure  of  the  liver.  By  now  passing  the  hand  further  to  the  left,  the 
left  extremity  of  the  gastro-hepatic  omentum  is  reached,  enclosing  the 
oesophagus,  and  the  hand  can  be  pushed  backward  between  the 
cardiac  end  of  the  stomach  below  and  the  left  lobe  of  the  liver  above 
until  the  inferior  layer  of  the  left  lateral  ligament  is  encountered,  at  the 
posterior  surface  of  the  left  lobe.  The  Spigelian  lobe  may  be  palpated 
by  passing  the  finger  through  the  foramen  of  Winslow,  and  then  up- 
ward between  the  spinal  column  (tenth  and  eleventh  dorsal  vertebrae 
covered  by  the  diaphragm)  and  the  liver.  The  surface  of  the  liver  so 
reached  is  the  Spigelian  lobe.  It  is  wholly  within  the  lesser  peritoneal 
sac.  Its  right  boundary  is  formed  by  the  inferior  vena  cava,  its  left 
by  the  oesophagus  and  cardia  of  the  stomach,  its  upper  boundary  by 
the  coronary  ligament  of  the  liver,  and  its  lower  by  the  transverse 
fissure  of  the  liver  (attachment  of  the  gastro-hepatic  omentum).  As 
the  finger  lies  in  the  foramen  of  Winslow  that  portion  of  the  liver  im- 
mediately above  it  is  the  caudate  lobe,  connecting  the  Spigelian  to  the 
right  lobe. 


20 


Anatomy. 


The  gall  bladder,  which  has  already  been  mentioned,  deserves 
further  notice.  Being  formed  as  an  outgrowth  from  the  duodenum 
along  with  the  liver,  it  grows  forward  beneath  this  organ,  and  is  en- 
veloped in  peritoneum  except  along  its  hepatic  surface.  Often  a  fold 
of  peritoneum  passes  nearly  directly  downward  from  the  fundus  of 
the  gall-bladder  to  the  hepatic  flexure  of  the  colon  (cystico-colic  liga- 


Fio.  lo. — The  Bile  Ducts  and  Theik  Relation  to  the  Duodenum  and  Pancreas. 


mcnt),  but  more  fre(|uently  the  ])eril()neum  covers  the  under  surface 
of  the  gall  bladder  closely,  and  ])asses  thence  to  the  duodenum.  These 
peritoneal  folds  have  been  i)articularly  studied  by  Sencerl.  The 
vestibule  of  the  foramen  of  Winslow  is  the  space  between  the  he])ato- 
colic  ligament  jjosteriorly  and  the  cystico  colic  ligament  anteriorly. 
Just  to  the  left  of  the  foramen  of  Winslow  is  the  alrium  biirscc  omentalis. 
The  cystic  duct  is  from  one  to  two  and  a  half  inches  (2.5  to  6.5  cm.) 


Topographical  Anatomy. 


21 


in  length,  and  joins  the  hepatic  duct  at  an  acute  angle,  to  form  the 
common  bile  duct.  The  cystic  duct  is  about  one-tenth  of  an  inch 
(2.5  mm.)  in  diameter.  The  hepatic  duct  is  usually  only  one  to  one 
and  a  half  inches  (2.5  to  4  cm.)  in  length,  and  is  formed  by  the  coales- 
cence of  the  right  and  left  bile  ducts  descending  from  the  liver.  Its 
diameter  is  one-sixth  or  one-quarter  of  an  inch  (4  to  6  mm.).  The 
common  bile  duct  is  from  one  to  three  inches  (2,5  to  7  cm.)  or  more  in 


Fig.  II. — Interior  of  Stomach,  Pylorus,  and  Duodenum,  Showing  Papilla  of 
Vater,  also  Orifice  of  Duct  of  Santorini. 


length,  compensating  for  the  shortness  of  the  other  ducts  when  they 
are  of  less  than  average  length.  It  is  about  one-quarter  of  an  inch 
(6  mm.)  in  diameter.  It  ordinarily  commences  a  little  above  the 
upper  level  of  the  pylorus,  and  passes  down  behind  this  and  the 
•descending  duodenum  in  front  of  the  pancreas,  until  it  is  joined  on  its 
posterior  side  by  the  pancreatic  duct.  As  it  passes  downward  it  may 
be  completely  enclosed  in  pancreatic  tissue.     The  combined  pan- 


22  Anatomy. 

creatic  and  bile  ducts  then  traverse  the  posterior  duodenal  wall  ob- 
liquely for  about  three  fourths  of  an  inch,  and  empty  into  the  interior 
of  the  descending  duodenum  about  three  or  four  inches  (7  to  10  cm.) 
beyond  the  pylorus.  To  obtain  a  good  view  of  this  opening  it  is 
necessary  to  open  the  anterior  duodenal  wall,  when  the  orifice  of  these 
ducts  will  be  perceived  as  a  slight  projection  of  the  mucous  membrane 
(papilla  of  Vater)  guarded  on  its  superior  surface  by  a  further  fold  or 
hood  of  mucous  membrane,  which  is  provided  with  a  frasnum.  Other 
similar  folds  are  sometimes  found  surrounding  the  papilla  of  Vater 
on  all  sides.  Gall  stones  not  infrequently  lodge  in  the  dilated  portion 
of  the  duct  known  as  the  ampulla  of  Vater,  just  outside  the  duodenal 
opening. 

The  arterial  supply  of  the  liver  is  conveyed  to  it  almost  entirely 
through  the  hepatic  artery,  a  branch  of  the  cceliac  axis.  By  a  some- 
what semicircular  course,  with  the  convexity  forward,  this  artery 
passes  across  the  inferior  border  of  the  foramen  of  Winslow  to  reach 
the  upper  border  of  the  pylorus,  where  it  enters  the  gastro-hepatic 
omentum,  holding  here  a  position  to  the  left  and  in  front  of  the  portal 
vein,  which  lies  behind  and  between  the  hepatic  artery  and  the  bile 
duct.  Its  length  is  from  one  and  a  half  to  two  inches  (4  to  5  cm.)  and 
in  diameter  it  is  not  far  from  a  quarter  of  an  inch  (6  mm.).  On 
reaching  the  transverse  fissure  of  the  liver  the  hepatic  artery  divides 
into  two  branches :  of  these,  the  right  passes  obliquely  to  the  right, 
usually  behind,  but  occasionally  in  front  of,  the  bile  ducts,  and  gives 
off  the  cystic  artery  to  the  gall-bladder.  The  cystic  artery  lies  between 
the  cystic  and  hepatic  ducts,  and  on  reaching  the  neck  of  the  gall- 
bladder divides  into  a  superior  and  an  inferior  branch,  which  supply 
the  corresponding  surfaces  of  the  gall-bladder.  The  left  hepatic 
artery,  which  is  shorter  than  the  right,  passes  to  the  left  extremity  of 
the  transverse  fissure,  and  supplies  branches  to  the  Spigelian  and  left 
lobes  of  the  li\xT. 

The  veins  of  the  liver  collect  the  blood  within  its  lobules,  and,  by 
radicles  of  gradually  increasing  size,  finally  em])ly  by  two  or  three 
trunks  directly  from  its  posterior  surface  into  the  inferior  vena  cava. 
Except  for  semilunar  folds  at  Ihe  entrance  of  these  veins  into  the  \ena 
cava,  no  valves  exist  throughout  the  he])atic  veins.     The  blood   is 


Topographical  Anatomy.  23 

urged  onward  largely  by  the  alternate  contraction  and  expansion  of 
the  liver  which  occurs  during  respiration. 

The  portal  vein,  as  is  well  known,  is  formed  in  front  of  the  body  of 
the  first  lumbar  vertebra  by  the  junction  of  the  superior  mesenteric 
and  splenic  veins.  At  its  origin  it  lies  between  the  head  of  the  pan- 
creas in  front  and  the  inferior  vena  cava  behind.  Then  passing  be- 
hind the  pylorus  and  first  part  of  the  duodenum,  it  enters  the  folds  of 
the  gastro-hepatic  omentum,  lying  behind  and  between  the  hepatic 
artery  on  the  left  and  the  bile  duct  on  the  right.  In  the  connective 
tissue  which  surrounds  it  lie  numerous  filaments  of  the  hepatic  plexus 
of  the  sympathetic  nerve,  as  well  as  some  efferent  lymphatics  from  the 
liver.  On  reaching  the  transverse  fissure,  the  portal  vein  divides  into 
two  branches,  right  and  left,  distributed  to  the  corresponding  lobes  of 
the  liver.  The  main  trunk  is  about  three  or  four  inches  (7  to  10  cm".) 
in  length.  The  portal  system  of  veins  drains  the  stomach,  the  whole 
of  the  small  intestine,  the  vermiform  appendix,  the  caecum,  the  ascend- 
ing, the  transverse,  and  most  of  the  descending  colon,  as  well  as  the 
spleen  and  the  pancreas.  The  cystic  vein  of  the  gall-bladder  also 
empties  into  the  portal  vein. 

There  are  certain  definite  connections  between  the  portal  vein  and 
the  systemic  veins,  which  are  of  importance  in  various  hepatic  con- 
ditions. These  connections  may  be  classified  as  (i)  those  within  the 
falciform  ligament  of  the  liver,  namely,  a  small  vein  which  sometimes 
is  present,  as  the  remains  of  the  umbilical  vein,  and  other  small  veins, 
known  as  para-umbilical  veins,  which  surround  the  round  ligament  of 
the  liver  and  anastomose  with  the  epigastric  and  mammary  veins  of 
the  abdominal  wall;  (2)  anastomoses  between  various  radicles  of  the 
portal  system  and  veins  of  the  posterior  abdominal  wall — as  between 
those  of  the  pancreas,  of  the  duodenum,  and  of  the  ascending  colon, 
with  veins  of  the  posterior  abdominal  wall,  such  as  the  lumbar  veins, 
the  azygos  veins,  etc.;  (3)  between  the  superior  hemorrhoidal  veins 
(tributaries  of  the  portal)  and  the  middle  and  inferior  hemorrhoidal 
veins  (tributaries  of  the  internal  iliac  veins) ;  (4)  certain  anastomoses 
between  the  tributaries  of  the  coronary  veins  and  the  oesophageal 
veins;  and  (5)  between  the  veins  of  the  portal  system  and  the  phrenics, 
at  the  uncovered  area  of  the  liver.     Of  these  various  communications 


24  Anatomy. 

the  most  important  are  the  first,  third  and  fourth  classes,  especially  the 
third  and  fourth.  Portal  obstruction  may  produce  the  "caput 
IMeduscT"  around  the  umbilicus  in  affecting  the  veins  of  the  falciform 
ligament;  in  this  case  the  current  of  blood  flows  away  from  the  um- 
bilicus and  the  para-umbilical  veins.  But  if  the  "caput  Medusas"  is 
due  to  obstruction  of  the  inferior  vena  cava,  then  the  course  of  the 
blood  is  reversed,  and  it  drains  toward  the  navel  into  the  veins  of  the 
round  ligament.  In  such  cases  there  is  also  sometimes  enlargement  of 
a  superficial  vein  connecting  the  epigastric  or  external  iliac  vein  with 
the  axillary,  which  is  easily  detected  as  it  runs  up  the  side  of  the  ab- 
domen and  chest.  Enlargement  of  veins  in  the  second  classification 
is  seen  chiefly  where  the  pancreas,  duodenum,  etc.,  are  bound  down  by 
adhesions,  and  their  normal  drainage  into  the  portal  system  is 
interfered  with.  Hemorrhoids,  one  of  the  most  annoying  and  constant 
symptoms  of  portal  obstruction,  are  produced  by  overdistention  of  the 
superior  rectal  veins;  and  as  the  communication  between  them  and 
the  middle  and  inferior  hemorrhoidal  veins  is  free,  all  three  sets  of 
rectal  veins  are  frequently  found  to  be  varicose.  The  importance  of 
varicose  veins  of  the  oesophagus  as  a  symptom  of  portal  obstruction 
has  been  particularly  insisted  upon  by  David  Riesman  of  this  city ; 
and  we  have  knowledge  of  more  than  one  patient  who  has  bled  to 
death  from  the  rupture  of  unsuspected  varicose  oesophageal  veins. 
The  case  reported  by  W.  J.  Taylor  will  be  again  referred  to. 

The  lymphatics  of  the  liver  are  divided  into  internal  and  external. 
The  former  accompany  the  branches  of  the  hepatic  and  portal  veins, 
and  are  not  of  so  great  surgical  importance  as  the  external  set.  Those 
accompanying  the  hepatic  veins  empty  into  the  lymph  nodes  situated 
on  the  upper  surface  of  the  diaphragm  just  above  the  caval  opening; 
while  the  lymph  vessels  accompanying  the  portal  veins  empty  into  the 
nodes  about  the  neck  of  the  gall-bladder  and  the  cystic  duct.  The 
external  lymphatics  of  the  liver  lie  under  its  peritoneal  covering,  and 
in  the  connective  tissue  of  the  capsule  of  Glisson,  and  all  drain  away 
from  the  interior  of  the  h'vcr.  They  consist  of  several  groups:  (i) 
Those  on  llic  u])])er  or  conx-ex  surface:  (a)  Three  or  four  branches 
pass  forward  along  the  upper  surface  of  the  hver  into  the  falciform 
ligament,  where  they  unite  into  a  single  trunk  which  enters  the  chest 


Topographical  Anatomy.  25 

through  the  small  diaphragmatic  opening  at  the  side  of  the  xiphoid 
cartilage,  and  joins  the  anterior  mediastinal  nodes,  eventually  emptying 
into  the  right  lymphatic  duct,  (b)  A  similar  group  turns  downward 
over  the  anterior  border  of  the  liver  to  its  under  surface,  passes  along 
the  longitudinal  fissure  to  the  transverse  fissure,  and  thence  to  the 
nodes  of  the  gastro-hepatic  omentum,  (c)  Some  lymphatics  from  the 
superior  surface  of  the  right  and  left  lobes  of  the  liver  pass  to  the  right 
and  left  lateral  ligaments,  and  enter  the  anterior  mediastinal  nodes  or 
the  lower  end  of  the  thoracic  duct.  (2)  The  external  lymphatics  from 
the  under  surface  of  the  liver  may  be  classified  as  follows :  fa)  Those 
on  the  right  of  the  gall-bladder  empty  into  the  lumbar  nodes;  (b) 
those  on  the  left  of  the  gall-bladder  pass  to  the  oesophageal  nodes  and 
to  the  nodes  along  the  lesser  curvature  of  the  stomach;  and  (c)  those 
surrounding  the  gall-bladder  form  a  plexus  and  pass  to  the  nodes  of 
the  gastro-hepatic  omentum.  It  is  thus  seen  that  the  lymph  nodes 
around  the  neck  of  the  gall-bladder  and  in  the  gastro-hepatic  omen- 
tum drain  the  following  areas  of  the  liver:  anterior  median  portion  of 
the  convex  surface,  gall-bladder  area,  and  all  of  the  inferior  surface  of 
the  left  lobe;  as  well  as  receive  the  deep  lymphatics  which  run  with 
the  branches  of  the  portal  vein.  These  nodes,  therefore,  in  the 
gastro-hepatic  omentum  are  the  most  important  surgically  of  all  the 
lymph  nodes  in  connection  with  the  liver,  and  are  frequently  found 
enlarged  in  gall-bladder  diseases,  in  malignant  growths,  and  in  in- 
flammations of  the  liver,  as  well  as  in  hepatic  cirrhosis.  They  are 
also  sometimes  enlarged  in  Hodgkin's  disease,  and  by  compression  of 
the  portal  vein  have  been  said  to  cause  ascites  in  this  affection;  but 
this  latter  action  has  been  questioned.  As  Rolleston  has  pointed  out, 
neoplasms  occasionally  work  their  way  into  the  liver  by  the  portal 
fissure  against  the  lymph  stream  which  normally  flows  outward  in 
this  location. 

The  nerve  supply  of  the  liver  is  derived  from  the  hepatic  plexus  of 
sympathetic  nerves,  which  receives  filaments  from  the  left  pneumo- 
gastric  and  the  right  phrenic  nerves.  This  plexus  accompanies  the 
ramifications  of  the  hepatic  artery  through  the  liver  substance,  and 
sends  branch  plexuses  along  the  pyloric  and  gastro-epiploic  arteries. 
A  cystic  branch  for  the  gall-bladder  is  also  derived  from  the  hepatic 


26  Anatomy. 

plexus.  The  right  phrenic  nerve  is  derived  mainly  from  the  fourth 
cervical  nerve,  which  also  sends  a  branch — the  supra-acromial  nerve — 
to  the  integument  of  the  point  of  the  shoulder,  thus  explaining  the 
"shoulder-tip  pains"  encountered  in  certain  hepatic  affections. 

The  disposition  of  the  peritoneum  and  the  relations  of  neighbouring 
organs  to  the  liver  form  what  has  been  well  described  by  M.  H. 
Richardson  as  the  "liver  pouch."  This  is  of  vast  importance  in  pre- 
venting infection  of  the  general  peritoneal  cavity  in  diseases  of  the 
gall  bladder  and  other  organs  in  the  upper  right  abdominal  quadrant. 
Limited  by  the  under  surface  of  the  right  lobe  of  the  liver  above,  by  the 
duodenum  and  spinal  column  toward  the  median  line,  and  by  the 
transverse  mesocolon  below,  this  pouch  readily  collects  all  extravasated 
fluids  and  becomes  a  valuable  site  for  drainage,  which  may  in  some 
instances  be  most  readily  procured  by  an  incision  into  its  floor  from 
the  loin,  below  the  inferior  pole  of  the  kidney. 

Duodenum. — The  duodenum,  with  the  exception  of  its  first 
portion,  is  entirely  retroperitoneal,  and  is  covered  in  front  by  so  many 
important  structures  that  only  its  first  and  second  portions  are  readily 
accessible  during  life.  The  first  portion,  continuous  with  the  pylorus, 
is  easily  reached  above  the  transverse  colon,  and  to  the  left  of  the  gall 
ducts.  The  descending  portion  is  best  exposed  by  dividing  the  outer 
layer  of  the  ascending  mesocolon  throughout  its  upper  third,  when  by 
rolling  the  ascending  mesocolon  together  with  the  pylorus  toward 
the  patient's  left,  the  outer  and  posterior  walls  of  this  portion  of  the 
duodenum  will  come  into  view;  the  bile  and  pancreatic  ducts  are  thus 
accessible  to  surgical  treatment.  To  expose  the  transverse  portion  of 
the  duodenum  the  least  dangerous  plan  is  to  divide  the  inferior  layer  of 
the  mesentery  of  the  small  intestine,  just  above  tlie  bifurcation  of  the 
aorta ;  this  gives  access  to  the  duodenum  as  it  crosses  the  spinal  column 
immediately  below  the  superior  mesenteric  vessels.  In  Jaboulay's 
entero-anastomosis  (p.  368)  the  transverse  portion  of  the  duodenum 
on  the  right  of  the  superior  mesenteric  artery  is  utilized.  The  duo 
dcno-jejunal  flexure  is  readily  found  by  turning  the  transverse  colon 
upward  and  seeking  for  the  origin  of  the  jejunum  as  the  small  in- 
testine emerges  from  beneath  tlie  transverse  mesocolon.  Below  and 
to  the  left  of  the  Icrminal  ])()rti()n  of  tlie  duodenum,  with  its  orifice 


\  Jsii^i^'  ■  -     ^'  raf^J^S'^:!^. 


F"iG.  12. — The  Origin  of  the  Jejunum,  and  the  Duodeno-jejunal  Fossa,  Ex- 
posed BY  Turning  the  Transverse  Colon  Upward. 


28  Anatomy. 

directed  upward,  is  the  duodeno-jejunal  fossa.  It  is  found  in  about 
48  per  cent,  of  cases,  and  may  be  the  seat  of  retroperitoneal  hernia. 

The  relations  of  the  duodenum  to  surrounding  organs  have  already 
been  considered.  Of  these  the  most  important  are  its  relations  with 
the  gall  bladder  and  with  the  transverse  colon.  From  the  former  it  is 
separated  by  two  serous  surfaces,  the  visceral  layer  covering  its  first 
and  second  portions,  and  the  visceral  layer  of  the  gall  bladder  itself. 
In  spite  of  this  fact  adhesions  are  frequent,  and  ulceration  of  the  duo- 
denum may  extend  into  the  gall  bladder,  or  vice  versa.  From  the 
transverse  colon  the  descending  duodenum  is  separated  only  by  a 
little  areolar  tissue,  there  being  no  peritoneum  between  the  two  organs 
where  the  root  of  the  transverse  mesocolon  crosses  the  duodenum. 
The  duodenum  is  fixed  in  its  position  not  only  by  its  retroperitoneal 
situation,  but  by  peritoneal  reflections  to  the  liver  and  gall  bladder 
from  its  initial  portion,  and  by  the  ligament  of  Treitz  from  the  duo- 
deno-jejunal juncture  to  the  diaphragm.  Besides  these  means  of 
fixation,  there  are  the  insertion  of  the  bile  and  pancreatic  ducts,  and 
the  proximity  of  the  superior  mesenteric  vessels  in  front  and  above  the 
duodenum. 

Ochsner  has  described  a  sphincter  of  the  duodenum,  consisting  of  a 
more  or  less  well  defined  band  of  thickened  circular  fibres,  usually 
some  distance  below  the  entrance  of  the  bile  and  pancreatic  ducts. 
He  thinks  it  is  of  assistance  in  the  phase  of  duodenal  digestion  by  re- 
taining the  chyme  in  the  duodenum  until  it  is  ready  to  be  discharged 
into  the  jejunum.  Boothby  has  been  unable  to  confirm  the  existence 
of  such  a  sphincter  in  any  of  25  specimens  examined  at  autopsy. 

Pancreas. — The  pancreas,  which  is  also  retroperitoneal,  is  covered 
anteriorly  by  the  posterior  parietal  layer  of  peritoneum  which  forms 
the  lesser  peritoneal  cavity.  It  is  best  exposed  through  the  gastro- 
colic omentum,  or  through  the  transverse  meso-colon.  The  latter 
route  gives  access  only  to  the  l^ody  and  tail,  since  the  middle  colic 
artery  would  have  to  be  divided  to  expose  the  head.  The  j)osterior 
portion  of  the  head  is,  however,  jxirtially  exposed  by  the  same  means 
advised  for  the  exposure  of  the  descending  duodenum,  and  ])an- 
crcatic  and  bile  ducts.  lUit  Ijy  dividing  the  gastro-colic  omentum 
close  to  the  colon,  leaving  the  gastro  cpi])loic  vessels  attached  to  the 


Topographical  Anatomy. 


29 


greater  curvature  of  the  stomach,  and  then  dividing,  within  the  lesser 
peritoneal  cavity,  the  superior  layer  of  the  transverse  mesocolon  over 
the  pancreas,  a  fairly  free  exposure  of  this  organ  throughout  its  whole 
length  is  obtained. 

The  hlood  supply  of  the  pancreas  is  derived  chiefly  from  the  pan- 
creatic branches  of  the  splenic.  This  artery  runs  in  a  very  tortuous 
course  along  the  upper  border  of  the  pancreas.  Situated  just  between 
the  coeliac  axis  above  and  the  superior  mesenteric  vessels  below, 
injuries  of  the  pancreas  are  almost  invariably  fatal  from  hemorrhage 


Fig.  13. — The  Pancreas,  its  Ducts,  and  Their  Relation  to  the  Duodenum. 


if  not  by  sepsis  or  lack  of  nutrition.  The  close  relation  borne  by  the 
pancreas  to  the  posterior  wall  of  the  stomach  explains  the  frequency 
with  which  this  organ  is  involved  in  carcinoma  of  the  stomach.  Pri- 
mary carcinoma  may  also  affect  the  pancreas,  and  the  growth,  if  it  in- 
volves the  head  of  the  organ,  may  cause  occlusion  of  the  common  bile 
duct  and  consequent  jaundice.  If  the  malignant  growth  affects  that 
part  of  the  organ  in  relation  with  the  aorta,  it  may  simulate  aortic 
aneurism  by  causing  a  swelling  over  which  transmitted  pulsation  is 
detected. 


30  Anatomy. 


REFERENCES. 

Boothby:     Boston  Med.  and  Surg.  Jour.,  1907,  July  18. 

Carle  and  Fantino:     Policlinico,  Roma,  1899,  ^h  Sez.  Chir.,  90. 

Cuneo:     Hartmann's  "Travaux  de  Chir.  Anatomo-clinique,"  Paris,  1903, 

i,  244. 
Delamere,  Poirier,  and  Cuneo,  "The  Lymphatics,"  translated    by 

Leaf.     Chicago,  1904,  p.  197. 
Jamieson  and  Dobson:     Lancet,  1907,  i,  1061. 
Ochsner:     Annals  of  Surgery,  1906,  i,  80. 
Robson  and  Moynihan:     Surgical  Treatment  of  Diseases  of  the  Stomach, 

New  York,  1904,  p.  5. 
Rolleston:     Diseases  of  the  Liver,  Philadelphia,  1905,  p.  83. 
Sencert:     Jour,  de  I'Anatomie,  1903,  xxxix,  353. 


CHAPTER  II. 

PHYSIOLOGY  OF  DIGESTION. 

The  region  of  the  upper  abdomen  includes  practically  all  of  that 
portion  of  the  intestinal  tract,  with  its  annexed  glands,  concerned  in 
the  process  of  digestion.  Although  the  intestines  below  the  duo- 
denum serve  as  a  receptacle  for  the  ingested  food,  and  although  the 
succus  entericus  has  certain  important  functions  to  perform  upon  the 
ingesta,  yet  these  parts  of  the  digestive  tube  are  concerned  more 
particularly  in  the  processes  of  absorption  and  elimination  than  in  that 
of  digestion. 

No  less  striking  than  the  developement  of  the  surgery  of  the  ab- 
domen during  the  last  decade,  are  the  valuable  contributions  to  our 
knowledge  of  the  physiology  of  digestion  which  are  products  of  the 
same  period.  There  is  no  better  illustration  of  the  fact  that  the  solu- 
tion of  physiological  problems,  which  has  baffled  master  minds  of 
bygone  days,  has  been  rendered  possible  only  by  the  employment  of 
modern  surgical  methods  in  investigations,  than  the  fact  that  the  ob- 
servations of  Beaumont  upon  Alexis  St.  Martin,  who  had  a  gastric 
fistula  caused  by  a  gunshot  wound,  have  been  considered  authori- 
tative from  1825  until  recent  times.  The  results  of  modern  investiga- 
tion have  such  important  clinical  relations  to  the  surgery  of  the  di- 
gestive system  that  they  well  merit  consideration  here. 

Intricate  though  the  processes  of  digestion  may  seem  at  first  sight, 
yet  a  knowledge  of  embryology  renders  these  problems  simple.^ 

Perusal  of  the  preceding  chapter  has  revealed  the  fact  that,  in  the 
foetus,  the  alimentary  canal  early  assumes  the  form  of  a  straight  tube. 
A  portion  of  this  tube  becomes  dilated,  and  forms  the  stomach.     New 

^  As  W.  J.  Mayo  expresses  it,  man  prepares  his  food  with  the  organs  which  have 
their  origin  in  the  foregut,  and  absorbs  his  nutrition  from  the  derivatives  of  the  midgut; 
that  is,  he  eats  with  the  jejunum  and  the  ileum  and  drinks  with  the  caecum. 

31 


32  Physiology  of  Digestion. 

relations  are  established  by  rotation  of  the  stomach  and  intestines. 
Evaginations  of  the  wall  of  the  duodenum  create  two  essential  glands, 
— the  liver  and  the  pancreas.  Analysis  of  this  growth-process  im- 
presses one  at  the  outset  with  two  striking  features :  first,  the  very  early 
appearance  of  the  rudiments  of  the  liver  and  pancreas,  and  secondly, 
the  great  extent  of  intestinal  coiling.  The  first  feature  suggests 
directly  that  glandular  activity  is  to  be  closely  associated  with  the 
workings  of  the  digestive  tube.  As  a  matter  of  fact,  the  latter  is  lined 
from  the  lips  to  the  anus  with  countless  glands.  The  developement  of 
any  gland  is  very  simple,  but  specialization  occasions  complexity. 
Cylindrical  ingrowth  of  the  epithelium  (which  in  this  case  lines  a 
cavity)  into  underlying  tissue,  with  subsequent  hollowing-out  of  the 
cylinders,  constitutes  a  gland  of  the  simple  unbranched  tubular  t^-pe, 
such  as  is  present  in  the  fundus  of  the  stomach,  or,  as  Lieberkuhn's 
glands,  throughout  the  small  and  large  intestines.  Offshoots  from 
the  cyKndcrs  estabhsh  the  type  of  simple  branched  tubular  glands, 
represented  by  the  countless  small  serous  and  mucous  glands  of  the 
oral  cavity,  and  by  the  glands  at  the  pylorus  of  the  stomach  and  in  the 
duodenum  (Brunner's  glands).  If  the  endings  of  the  epithelial  plugs 
expand  and  secondarily  give  rise  to  primary  alveoli,  there  is  produced 
the  racemose  type  of  glands,  such  as  the  salivary  glands  and  pancreas. 
Further  and  more  complicated  modifications  of  structure  produce  a 
reticular  tubular  gland,  such  as  the  Hver,  in  which  instance  the  anasto- 
mosis between  the  branches  of  the  tubular  glands  is  so  extensive  that  a 
net-like  structure  is  produced.  The  salivary  glands,  pancreas,  and 
liver  are  distinguished  by  ducts  of  various  lengths,  so  that  we  may 
designate  them  extra-mural  glands.  To  sum  up,  therefore,  we  are 
imjjrcssed  with  the  fact  that  innumerable  glands  line  the  digestive 
tuJK',  and  that,  where  the  ref|uircmcnts  of  the  organism  demand  it, 
several  glands  arc  further  developed  and  si)eciali/ed,  and  arc  removed 
from  the  walls  of  the  digestive  tube  to  undergo  further  enlargement, 
but  are  still  connected  with  this  tube  by  ducts  of  varying  lengths.  The 
aggregate  of  output  of  these  f^lands  is,  therefore,  very  considerable. 
Sappey  has  calculated  that  the  surface  of  the  mucous  membrane  of  the 
human  stomach  ])rcsents  over  5,000,000  orifices  of  gastric  glands. 
Digestion  may  be  defined  as  a  mcclianical  and  (  hemiral  ])rocess 


Digestion.  33 

by  which  food  is  prepared  for  absorption.  Of  course  it  is  useless,  in  a 
work  which  aims  to  treat  of  practical  questions  in  the  surgery  of  the 
upper  abdomen,  to  discuss  at  length  the  various  theories  and  facts  in- 
volved in  the  study  of  human  digestion;  but  it  is  unavoidable  to  offer 
readers  of  such  a  work  some  sort  of  reference  chapter,  which  will 
serve  to  illustrate  the  main  principles  of  physiology  involved,  and  will 
enable  them  to  orientate  their  knowledge  when  discussing  the  path- 
ology and  treatment. 

Digestion  means  the  intake  of  food,  its  mastication,  its  exposure  to 
the  action  of  various  secretions,  to  intestinal  movements,  to  absorption, 
and  finally,  if  of  no  further  use  to  the  organism,  its  elimination.  Na- 
ture prepares  a  very  difficult  gauntlet  for  the  food  to  run,  so  as  to  ex- 
tract from  it  every  possible  iota  of  nutrition.  Prolonged  contact  with 
the  food  is  secured,  in  the  first  instance,  by  coiling  of  the  small  bowel, 
and  sacculation  of  the  large;  and,  secondarily,  by  the  presence  of  the 
valvulae  conniventes  and  villi  in  the  small  intestine.  Not  only  is  the 
area  of  absorption  incalculably  increased  in  this  way,  but  also  the 
capacity  of  secretion  is  augmented  manifold. 

As  regards  function,  practically  all  of  the  glands  in  connection 
with  the  gastro-intestinal  tract  are  capable  of  secreting  mucus,  the 
lubricant.  Some  few  secrete  serous  fluid,  the  diluent.  To  fewer 
still  is  reserved  the  property  of  secreting  more  highly  specialized 
products,  the  enzymes.  Two,  the  liver  and  pancreas,  are  concerned 
also  in  internal  secretion. 

Food  stuffs,  as  we  all  know,  are  classed  as  Proteids,  Carbo- 
hydrates, and  Fats,  respectively  represented  by  meats,  by  sugars  and 
starches  (rice,  macaroni,  bread,  etc.),  and  by  fatty  substances  such  as 
butter,  eggs,  cheese,  and  fat  of  meats.  When  digested  and  therefore 
prepared  for  absorption,  it  may  be  stated  with  sufficient  accuracy  that 
proteids  become  peptones,  that  carbohydrates  become  maltoses,  and 
that  fats  are  absorbed  practically  unchanged. 

The  proteid  is  acted  upon  by  three  agencies,  namely,  the  pepsin 
of  the  stomach,  the  trypsin  of  the  pancreas,  and  the  bacteria  in  the 
large  intestine.  The  carbohydrate  constituent  is  disposed  of  by  three 
agencies,  the  ptyalin  of  the  parotid  glands,  the  amylopsin  of  the  pan- 
creas, and  amylolytic  enzymes  from  Lieberkiihn's  glands  of  the  small 
3 


34  Physiology  of  Digestion. 

intestine.  The  fats  arc  attacked  by  the  lipase  (steapsin)  of  the  pan- 
creas, an  enzyme  the  activity  of  which  is  enhanced  by  the  bile.  There 
are  other  less  important  enzymes. 

The  mechanical  part  of  digestion  is,  or  should  be,  performed 
largely  by  the  cooking  and  by  the  mastication  of  the  food  before  it  ever 
reaches  the  stomach.  After  being  swallowed,  the  action  of  the  stom- 
ach consists  both  in  a  churning  movement  which  mixes  the  bolus  of 
food  with  the  gastric  juices,  as  well  as  in  a  rhythmic  peristalsis  by 
which  the  food  is  from  time  to  time  urged  forw^ard  into  the  duodenum. 
Beyond  the  pylorus,  practically  the  only  mechanical  action  to  which 
the  ingesta  are  subjected,  apart  from  the  peristaltic  motion  of  the 
intestines,  is  represented  by  the  dilution  which  they  undergo  by  ad- 
mixture with  the  bile  and  with  the  pancreatic  and  intestinal  juices. 
So  great  is  this  dilution  that  although  much  of  the  fluid  portions  of  the 
food  is  absorbed  while  passing  through  the  small  intestine,  yet  even 
when  the  ctecum  is  reached  the  intestinal  contents  are  always  very 
soft,  and  usually  semifluid. 

From  the  standpoint  of  anthropology,  cooking  of  foods  is  not 
essential  to  the  welfare  of  mankind,  but  is  a  product  of  civilization. 
This  trespass  upon  Nature  has  resulted  in  an  inherited  tendency  of 
the  human  teeth  toward  premature  decay  on  account  of  decreased 
necessity  for  the  grinding  action.  The  possession  of  poor  teeth  pre- 
disposes to  gastro-intestinal  affections,  whilst  a  good  set  acts  as  a 
powerful  prophylactic.  However,  cooking  of  meat  sets  free  the  muscle 
fibres  by  its  action  on  the  connective-tissue,  which  it  partly  transforms 
into  gelatin.  Cooking  of  vegetables  springs  the  peUicle  and  renders 
the  starch  more  soluble.  In  bread  baking,  the  dough  is  spongilied  by 
the  carbonic  acid  formed  from  the  yeast.  Furthermore,  cooking 
kills  parasitic  ova,  and  renders  food  sterile. 

The  prophase  of  digestion  is  initialed  by  the  senses  of  sight, 
smell,  and  hearing,  and  also  ])\  the  thought  of,  and  longing  for,  food. 
Careful  and  attractive  ])re])aration  of  food,  and  savory  odours  that 
emanate  from  it,  powerfully  whet  the  a]:)petitc.  A])])elitc  is  stimulated 
through  the  sense  of  hearing,  by  clatter  of  dishes  and  the  sizzling  of 
meat  directly  removed  from  the  fire.  The  craving  for  food  is  in- 
stinctive, and  is  the  basis  of  the  appetite. 


Salivary  Digestion.  35 

Salivary  Digestion. — These  psychic  events  bring  about  a  flow  of 
saliva,  as  a  preparatory  step  to  the  introduction  of  food  into  the 
mouth.  The  presence  of  food  in  the  mouth  causes  additional  flow  of 
saliva,  which  now  is  adapted  to  the  character  of  the  material  ingested. 
The  secretion  from  the  parotid  glands  is  serous,  and  contains  the 
enzyme,  ptyalin;  that  from  the  sublingual  and  numerous  minute 
glands  in  the  mouth  is  mucous,  whilst  the  secretion  of  the  submaxillary 
glands  is  mixed,  serous  and  mucous.  By  moistening  the  food,  saliva 
aids  mastication,  and  by  enveloping  the  hard  and  bulky  bolus  with 
mucin,  it  facilitates  deglutition.  It  dissolves  the  soluble,  a  step 
necessary  for  inauguration  of  taste  sensations.  Furthermore,  saliva 
is  protective  in  that  it  tests  materials  introduced  into  the  mouth, 
neutralizing  deleterious  properties,  rejecting  the  harmful,  and  wash- 
ing out  injurious  substances  which  might  enter  the  blood  through 
contact  with  the  mucous  membrane.  A  specific  excitability  is  mani- 
fested by  the  salivary  glands,  since  fresh,  moist  food  creates  but  little 
secretion,  whilst  dry  materials  induce  a  copious  flow.  The  amylase 
(ptyalin)  from  the  parotid  gland  changes  starch  into  dextrin  and 
maltose.  Owing  to  the  short  stay  of  food  in  the  mouth,  salivary 
digestion  takes  place  chiefly  in  the  stomach.  Although  destroyed  by 
gastric  juice,  yet  ptyalin  continues  its  action  in  the  interior  of  the 
bolus  of  food  until  the  gastric  juice  has  completely  penetrated  the 
mass,  a  process  which  rec|uires  from  20  to  40  minutes. 

Gastric  Digestion. — Before  the  food  reaches  the  stomach, 
gastric  juice  has  been  secreted  by  the  innumerable  tubular  glands 
which  stud  thickly  the  gastric  mucosa.  The  excitant  of  this  pre- 
liminary flow  is  psychic;  in  fact  it  resides  in  the  appetite,  and  hence  we 
may  speak  of  "appetite-juice."  The  latter,  which  appears  within  5 
minutes,  is  copious  in  amount,  and  strong  in  digestive  power.  A  good 
appetite  in  eating  is  equivalent  from  the  outset  to  a  vigorous  secretion 
of  the  strongest  juice;  lacking  appetite,  this  juice  is  also  absent. 
Restoration  of  appetite  means  gastric  juice  in  plenty,  wherewith  to 
inaugurate  digestion.  The  gastric  glands  may  be  as  active  during 
sleep  as  in  the  waking  hours. 

The  qualitative  secretion  of  the  gastric  glands  varies  in  difterent 
parts  of  the  stomach.     In  the  fundic  region  pepsin,  rennin,  and 


36  Physiolog}^  of  Digestion. 

scanty  amounts  of  hydrochloric  acid  are  secreted;  in  the  pre-pyloric 
region  the  same  substances  and  most  of  the  hydrochloric  acid,  the 
latter  fact  being  indicated  by  the  deeper  red  color  of  the  mucous  mem- 
brane in  this  area;  whilst  in  the  pyloric  region  pepsin  and  rennin  only 
are  produced. 

In  the  stomach  the  ingesta  undergo  equalization  of  temperature, 
maceration  by  the  gastric  juice,  and  conversion  into  chyme.  Al- 
though ptyalin  is  destroyed  in  an  acid  medium,  yet  salivary  digestion 
of  carbohydrates  may  proceed  for  30  minutes  in  the  stomach,  not  only 
on  account  of  the  slight  acidity  of  the  gastric  juice  in  the  fundus  where 
the  food  first  lodges,  but  also  because  of  the  length  of  time  required 
for  complete  penetration  of  each  bolus  of  food  by  the  gastric  juice. 
The  copious  amount  of  "appetite-juice"  is  now  augmented  by  a 
second  quantity  of  juice,  produced  chemically.  The  first  comple- 
ment of  juice  decreases  in  amount  as  the  second  increases.  The 
latter  depends  on  the  production  in  the  pyloric  mucous  membrane  of  a 
specific  substance  or  hormone,  which  acts  as  a  chemical  messenger  to 
all  parts  of  the  stomach,  being  absorbed  into  the  blood  and  thence 
exciting  the  activity  of  the  various  secreting  cells  in  the  gastric  glands. 

Just  as  the  acidity  of  the  gastric  juice,  which  is  equivalent  to  0.48 
per  cent,  hydrochloric  acid,^  is  detrimental  to  the  action  of  ptyalin, 
so  is  it  essential  for  the  action  of  the  ferment,  pepsin.  During  the 
time  usually  occupied  by  gastric  digestion,  namely,  from  3  to  6  hours, 
proteids  arc  prepared  by  the  pepsin-hydrochloric  acid  for  subsequent 
digestion  by  the  enzyme,  trypsin,  in  the  small  intestine.  With  this 
end  in  view,  most  of  the  protcid  is  converted  in  the  stomacli  into  its 
first  products  of  hydration,  namely,  peptones  and  proteoses,  in  which 
state  the  proteids  of  the  food  are  normally  passed  on  into  the  duo- 
denum, having  been  rendered  more  amenable  to  the  action  of  tryj^sin. 
Therefore,  disposal  of  proteids  occurs  in  tlic  cycle  of  ])e])tic-tr}q^)tic 
digestion. 


'  Thus  when  a  patient  is  reported  as  having  a  gastric  acidity  of  60,  the  statement 
signifies  that  the  total  acidity  is  above  the  nonnal;  in  other  words  that  tlicre  is  hyjicr- 
chlorhydria.  If,  on  the  other  hand,  the  total  aridity  is  reported  as  35  or  40,  the  acidity 
is  clearly  below  the  normal.  The  "free"  add  of  llic  gastric  juice  normally  varies 
between  o.i  and  0.2  per  cent. 


Gastric  Digestion.  37 

Rennin  possesses  the  specific  action  of  curdling  milk,  which  is 
brought  about  by  the  coagulation  of  caseinogen. 

Fat  undergoes  no  digestive  change  in  the  stomach.  It  is  merely 
liquefied  by  the  bodily  heat,  dissociated  from  other  foods  by  the 
specific  proteolytic  action  of  the  pepsin-hydrochloric  acid,  and  mixed 
with  the  chyme  in  the  form  of  a  coarse  emulsion.  Fat  inhibits  the 
work  of  the  gastric  glands,  both  from  a  quantitative  and  from  a  quali- 
tative point  of  view:  hence  the  omission  of  fat  other  than  in  emulsion, 
from  a  corrective  dietary.  On  the  contrary,  water  and  extracts  of 
meat  exert  a  stimulating  effect  upon  the  secretion  of  gastric  juice. 

Absorption  from  the  stomach  is  very  sKght,  although  alcohol  is 
absorbed  readily,  and  certain  soluble  drugs  may  be. 

Gastric  digestion  continues  until  the  whole  of  the  stomach  con- 
tents is  discharged  from  the  pylorus  as  the  semifluid  chyme.  After 
this  event,  the  stomach  enters  upon  a  resting  stage,  during  which  its 
cavity  is  practically  obliterated. 

Intestinal  Digestion. — The  fluid  chyme,  on  entering  the  duo- 
denum, is  subject  at  once  to  the  influence  of  the  secretions  of  3  differ- 
ent sets  of  glands,  namely:  (i)  The  intestinal  glands,  including 
those  characteristic  of  the  duodenum,  called  Brunner's  glands;  (2) 
the  pancreas;  (3)  the  liver.  The  ducts  of  the  two  latter  in  man  have 
a  common  opening  into  the  duodenum,  and  there  is  a  co-operation 
between  all  three  juices  for  the  production  of  the  intestinal  digestive 
fluid. 

The  flow  of  pancreatic  juice  is  initiated  chemically.  The  epithe- 
lial cells  lining  the  gut  contain  a  body — ^pro- secretin — which,  under 
the  influence  of  agents  such  as  acids,  undergoes  hydrolysis  with  the 
splitting  off  of  a  new  body,  termed  secretin.  The  latter,  on  absorption 
into  the  blood,  acts  as  the  chemical  messenger  (hormone)  to  the  pan- 
creatic cells.     Sleep  does  not  hinder  pancreatic  secretion. 

The  pancreatic  juice  is  alkaline,  a  reaction  that  corresponds  closely 
in  degree  to  the  acidity  of  the  gastric  juice.  xA.ided  by  the  bile  and 
alkaline  juice  from  the  intestinal  glands,  the  pancreatic  juice  neutral- 
izes the  acid  chyme,  with  the  result  that  a  neutral  fluid,  in  which  the 
processes  of  intestinal  digestion  will  go  on,  is  produced  in  the  duo- 
denum. 


38  Physiology  of  Digestion. 

Secretion  of  pancreatic  juice  starts  shortly  after  entrance  of  food 
into  the  'Stomach,  and  rapidly  reaches  a  maximum  in  from  2  to  4 
hours,  whilst  by  the  seventh  hour  it  has  practically  ceased.  The 
character  of  the  food  modifies  the  composition  of  the  secretion.  The 
pancreatic  juice  when  it  reaches  the  duodenum  contains  three  en- 
zymes, of  which  trypsin  is  proteolytic;  amylopsin,  amylolytic;  and 
steapsin,  lipolytic.  Secretion  evoked  by  proteids  abounds  in  trypsin; 
that  by  carbohydrates,  in  amylopsin;  and  that  by  fats,  in  steapsin. 

If  trypsin  be  proteolytic,  the  question  would  naturally  arise,  why 
should  not  this  enzyme  digest  the  intestinal  mucosa  ?  The  answer  is 
contradictory.  Trypsin  is  not  a  secretion,  but  a  resultant.  The 
secretion  is  trypsinogen,  a  pro-enzyme,  which  is  converted  into  tryp- 
sin by  enterokinase,  a  product  of  the  duodenum  and  jejunum.  There- 
fore, until  enterokinase  trans-substantiates  tr}q3sinogen  into  tr}']3sin  by 
catalysis,  no  proteolysis  is  manifested. 

Tr}^sin  continues  the  transformation  of  proteids  that  was  begun 
in  the  stomach.  It  also  completes  the  cycle  of  peptic-tryptic  digestion. 
Trypsin,  however,  acts  more  rapidly  and  powerfully  than  pepsin,  and 
breaks  up  the  proteid  molecule  more  completely.  Thus,  the  peptones 
and  proteoses,  prepared  from  proteids  by  the  pepsin,  and  delivered  by 
the  stomach  into  the  duodenum,  are  further  split  by  trypsin  into 
amido-acids. 

Amylopsin  acts  upon  starches  in  very  much  the  same  way  as  does 
ptyalin.  The  carbohydrates  tliat  have  escaped  the  action  of  pytalin 
are  hydrolyzcd  in  the  duodenum,  by  amylo])sin,  into  maltose  and 
dextrin ;  and  these,  in  turn,  are  converted  into  dextrose  by  the  maltase 
of  the  succus  cntericus. 

Stcajjsin,  materially  aided  by  bile,  splits  u])  neutral  fats  into 
glycerin  and  free  fatty  acids. 

The  Secretion  of  Bile. — Since  Ijile  reaches  tlic  (huKlcnum 
through  an  orifice  common  to  it  and  to  llic  pancreatic  juice,  tlie  in- 
ference naturally  is  drawn  that  tliese  two  lluids  c()-o])eratt'  in  their 
action,  and  that  ])ile  is  of  (h'rect  use  in  (h'geslion.  As  a  mailer  of  fact, 
bile  increases  the  action  of  steapsin  two  to  three  fold,  and  that  of 
trypsin  and  amylojjsin  about  two  fold.  Indeed,  bile  is  of  great  value 
in  digestion,  and  ])lays  an  im])ortant  role  in  this  process.      Beginning 


Intestinal  Digestion.  39 

almost  immediately  after  taking  food,  the  secretion  of  bile  atta'ns  its 
maximum  with  the  pancreatic  juice  in  the  third  hour,  is  regulated  by 
the  same  laws  that  govern  the  flow  of  other  digestive  juices,  and  then 
rapidly  declines.  Thus,  bile  is  produced  by  the  same  agent  as  pan- 
creatic juice,  namely,  by  secretin.  Furthermore,  bile  flows  as  long  as 
digestion  lasts,  but  with  definite  fluctuations  in  quantity  and  quality, 
dependent  upon  the  nature  of  the  food. 

The  bile  is  being  constantly  formed  in  the  liver,  and,  during  the 
intervals  of  digestion,  is  stored  up  in  the  gall-bladder.  Its  pressure  is 
not  known  accurately,  but  is  believed  to  be  always  greater  than  that  of 
the  blood  in  the  portal  vein.  In  amount  the  bile  varies  from  twenty  to 
twenty-seven  ounces  f6oo  to  800  cc.)  daily.  It  is  propelled  from  the 
liver  into  the  gall-bladder  by  the  muscular  contractions  of  the  larger 
bile  ducts;  and  is  again  ejected  into  the  duodenum  in  spurts  by  con- 
tractions of  the  gall-bladder.  Its  descent  from  the  liver  is  possibly 
aided  by  gravity  and  by  the  changes  in  the  bulk  of  the  liver  produced 
by  respiration,  as  well  as  by  the  vis  a  tergo  of  the  more  freshly  formed 
bile.  The  contraction  of  the  gall-bladder  is  usually  believed  to  be 
produced  by  sensory  stimulation  of  the  mucous  membrane  of  the 
stomach  or  duodenum  through  reflex  nervous  action.  The  presence 
of  chyme  in  the  duodenum  causes,  by  means  of  secretin,  a  contraction 
of  the  gall  bladder  and  a  relaxation  of  the  sphincter  surrounding  the 
duodenal  orifice  of  the  bile  duct,  with  consequent  ejection  of  bile.  It 
is  an  interesting  fact  that  even  though  almost  the  whole  amount  of  bile 
excreted  be  diverted  through  a  biliary  fistula,  so  that  scarcely  any  of 
it  reaches  the  intestinal  tract,  yet  nevertheless  the  individual  so  affected 
may  continue  to  enjoy  good  health,  showing  conclusively  that  bile  is 
much  more  of  an  excretion  than  a  secretion. 

To  sum  up,  the  chief  duty  of  the  bile  is  to  facilitate  the  transition 
from  gastric  to  intestinal  digestion,  since  it  enters  the  duodenum  at  a 
spot  where  the  acid  peptic  digestion  gives  place  to  alkaline  pancreatic 
digestion;  it  arrests  the  action  of  pepsin,  which  is  mischievous  to  the 
enzymes  of  the  pancreatic  juice,  and  reenforces  the  enzymes  of  the 
latter,  particularly  by  serving  as  a  vehicle  for  the  suspension  and 
solution  of  the  interacting  fats,  fatty  acids,  and  steapsin. 

Not  only  is  bile  important  in  digestion,  but  further,  as  an  excretion, 


40  Physiology  of  Digestion. 

it  is  the  channel  by  which  the  disintegration-products  of  haemoglobin 
are  cast  out  from  the  organism. 

Succus  Entericus  increases  the  activity  of  the  pancreatic  enzymes. 
Just  as  bile  aids  particularly  the  action  of  the  pancreatic  lipolytic 
enzyme,  so  does  succus  entericus  augment  the  proteolytic.  Hence, 
both  of  these  secretions  are  adjuvants  of  the  pancreatic  juice.  Se- 
cretin is  also  the  producer  of  succus  entericus. 

Succus  entericus  is  a  secretory  product  of  some  of  the  glands  of 
Lieberkiihn.  Collectively,  these  glands,  as  well  as  those  of  the 
stomach,  may  be  considered  as  an  enzyme-producing  entity  which, 
instead  of  being  gathered  together  to  form  an  extramural  organ, 
such  as  the  liver  or  pancreas,  are  distributed  throughout  the  intestinal 
wall,  thence  to  discharge  secretion  directly  into  the  lumen  of  the 
intestine. 

Succus  entericus,  distinctly  alkaline  in  reaction  owing  to  sodium 
carbonate,  contains  four  or  five  enzymes  that  complete  the  digestion  of 
food-stuffs  begun  in  the  stomach  and  duodenum,  thus  exercising  a 
most  important  influence  upon  intestinal  digestion.  Of  these  enzymes 
two,  enterokinase  and  erepsin,  are  concerned  in  proteolysis.  Entero- 
kinase,  as  has  been  seen,  activates  the  proteolytic  enzyme  of  the  pan- 
creatic juice,  by  converting  the  trypsinogen  into  trypsin.  Erepsin 
supplements  the  work  begun  by  trypsin,  in  that  it  causes  further  hy- 
drolysis of  peptones  and  proteoses. 

Secretin,  which  initiates  the  secretion  of  bile,  pancreatic  juice,  and 
succus  entericus,  is  not  an  enzyme,  but  a  definite  chemical  substance 
produced  in  the  intestinal  wall  in  a  preliminary  form,  pro- secretin, 
which,  influenced  by  acids,  is  converted  to  secretin.  The  latter  is 
absorbed  and  carried  to  the  glands,  the  secretion  of  which  it  evokes. 

The  remaining  enzymes  of  succus  entericus  are  concerned  in  the 
digestion  of  carbohydrates.  They  arc  maltase,  invcrtase,  and  lactase, 
the  last  being  present  in  young  individuals  and  in  those  fed  through- 
out life  exclusively  upon  a  milk  diet.  Maltase  acts  upon  the  products 
of  the  digestion  of  starches,  namely,  maltose  and  dextrin,  converting 
them  into  dextrose.  Invcrtase  transforms  cane  sugar  into  dextrose 
and  Icvulose,  whilst  lactase  changes  milk-sugar  into  dextrose  and 
galactose. 


Intestinal  Digestion.  41 

Absorption  in  the  Intestines. — In  consequence  of  all  these 
changes,  the  three  classes  of  food-stuffs  are  reduced  to  a  soluble  con- 
dition, and  in  solution  are  taken  up  by  the  cells  lining  the  intestine. 
The  products  formed  in  digestion  largely  disappear  between  the  duo- 
denum and  the  ileocaecal  valve.  Carbohydrates  are  absorbed  chiefly 
as  simple  sugars — monosaccharids.  As  dextrose,  then,  the  sugars 
pass  directly  into  the  blood  stream,  by  which  they  are  distributed  first 
to  the  liver  and  then  to  other  organs  of  the  body.  In  the  liver  the 
excess  of  sugar  is  removed  from  the  blood  and  stored  as  glycogen. 
Alimentary  glycosuria  is  a  phenomenon  arising  from  ingestion  of 
larger  amounts  of  carbohydrates  than  the  liver  can  store  up  as  glycogen, 
the  excess  being  removed  from  the  blood  by  the  kidneys,  and  excreted 
in  the  urine.  Any  carbohydrates  which  escape  absorption  as  sugar 
are  apt  to  undergo  acid  fermentation  from  the  action  of  the  bacteria 
constantly  present  in  the  intestine. 

Proteids,  hydrolyzed  during  digestion  into  peptones  and  proteoses, 
or  amido-acids,  probably  are  absorbed  as  such,  passing  directly  into 
the  blood-vessels  of  the  intestinal  villi,  and  thence  into  the  blood 
stream. 

Fats  are  absorbed  by  the  epithelial  cells  in  the  forms  of  fatty  acids 
and  glycerin,  which,  in  turn,  are  immediately  re-synthesized  into  in- 
soluble neutral  fats  in  the  cells  themselves.  In  the  state  of  the  fine 
emulsion — chyle — most  of  the  fats  reach  the  blood  stream  through  the 
lacteals  and  thoracic  duct.  Absorption  of  split  fats  is  considerably 
aided  by  the  bile.  Some  of  the  fat  reaches  the  liver  by  way  of  the  blood 
stream,  and  undergoes  accumulation  in  that  organ.  If  an  excess  of  fat 
were  ingested,  or  if  the  flow  of  bile  were  decreased  or  stopped,  a  large 
percentage  of  fat  would  escape  absorption  and  appear  in  the  faeces. 

The  secretion  of  the  large  intestine  is  alkaline,  and  contains  much 
mucus,  but  is  itself  devoid  of  enzymes,  those  that  are  present  having 
been  contributed  and  passed  along  by  the  small  gut.  Since  absorp- 
tion and  digestion  are  not  completed  in  the  small  intestine,  they  are 
continued  in  the  large.  Furthermore,  the  latter  absorbs  large  quan- 
tities of  water. 

Bacterial  Action. — The  bacteria  normally  found  in  the  intestinal 
tract  are  of  considerable  practical  importance.     At  birth  the  digestive 


42 


Physiology  of  Digestion. 


tract  is  sterile,  but  as  soon  as  unsterilized  food  is  ingested  there  are 
found  bacteria  of  various  kinds,  pre-eminently  the  colon  bacillus. 
As  has  been  shown  by  numerous  observers,  the  emptier  the  intestinal 
tract  is  of  food,  the  fewer  will  be  the  bacteria  present.  In  the  stomach, 
bacteria  disappear  with  the  food,  and  when  the  stomach  has  been 
entirely  empty  for  some  time,  its  cavity  is  practically  sterile,  owing  to 
the  antiseptic  properties  of  the  gastric  juice.  Certain  bacteria,  es- 
pecially the  Bacillus  subtilis  and  the  Proteus  vulgaris,  are  believed  to 
have  a  proteolytic  action,  and  thus  to  aid  the  peptic  digestion.  The 
duodenum  in  its  upper  part  is  singularly  free  from  bacteria,  probably 
due  also  to  the  acid  gastric  juice;  but  as  the  small  intestine  is  traversed 


/oo.ooo 

90,000 
80,000 
70,000 
60,000 

so.ooo 

40,000 
30,000 
20,000 
10,000 
Q 


Stomach  Duodenum 


Jrju 


Ilev.m 


Large  Intestut  e 


Fig.  14. — Graphic  Representation  or  the  Bacterial  Content  or  the  Gastro- 
intestinal Tract. 


the  Ijactcrial  content  Ijccomcs  greater  and  greater,  reaching  its  max- 
imum in  the  lower  ileum;  l)ut  wlien  the  acid  secretions  of  the  large 
intestine  are  reached,  it  falls  again  as  low  as  it  was  in  the  duodenum. 
The  annexed  diagram  from  Gilbert  and  Domenici  describes  these 
changes  much  more  accurately  than  can  mere  words.  The  practical 
application  of  these  ])rinciples  has  been  nowhere  more  successfully 
carried  out  in  surgery  than  by  Gushing  at  the  Johns  H()])kins  Hospital. 
It  is  worthy  of  note  that,  just  as  puriration  eliminates  most  of  the  bac- 
teria with  the  intestinal  ('()nlcnl>,  so  proloniiird  constipation  and  es- 
jjecially  intestinal  obstruction  markcdl)  Iik  rcascs  tlie  \irulence  of  the 
intestinal  bacteria. 


Intestinal  Digestion.  43 

In  the  small  intestine,  bacteria  show  activity  by  fermenting  car- 
bohydrates. This  process  exerts  a  restraining  effect  upon  proteid 
putrefaction,  which,  on  the  contrary,  is  a  constant  and  normal  oc- 
currence in  the  large  intestine.  In  this  way  proteids  that  have  escaped 
digestion  and  absorption  are  split  up  into  various  end-products,  some 
of  which  are  given  off  in  the  fasces,  whilst  others  are  absorbed  in  part 
and  excreted  subsequently  in  the  urine.  The  extent  to  which  these 
bodies  occur  in  the  urine  is  an  indication  of  the  extent  of  putrefaction 
in  the  large  intestine,  a  fact  which  possesses  certain  clinical  value. 
Cellulose,  for  which  there  is  no  specific  enzyme,  is  hydrolyzed  by 
bacteria  and  thus  rendered  useful  in  nutrition,  inside  from  this,  it 
may  be  said  that  bacterial  fermentation  is  not  essential  for  the  welfare 
of  the  oeconomy. 

Composition  of  the  Faeces. — The  character  of  the  food  has  an 
important  influence  upon  the  composition  of  the  faeces.  Upon  a  diet 
composed  exclusively  of  meats  they  are  small  in  amount  and  dark  in 
colour ;  with  an  ordinary  mixed  diet  the  amount  is  increased ;  and  it  is 
largest  with  an  exclusively  vegetable  diet,  especially  with  vegetables 
containing  a  large  amount  of  indigestible  substances.  Faeces  are 
made  up  of  indigestible  and  undigested  materials;  products  of  in- 
testinal secretions  and  of  bacterial  decomposition;  cholesterin,  ex- 
cretin,  mucus  and  epithelial  cells,  pigment,  inorganic  salts,  and  micro- 
organisms. In  addition,  gas,  arising  from  bacterial  fermentation  of 
proteids,  is  present  in  varying  amounts. 

The  main  function  of  the  alimentary  tract,  therefore,  is  the  pres- 
entation to  the  tissues  of  the  body  of  the  food-stuffs  in  a  form  in  which 
they  are  directly  assimilable. 

Liver. — Our  knowledge  of  the  physiology  of  the  liver  has,  until 
recent  years,  consisted  in  acquaintance  with  the  facts  that  it  produced 
bile,  and  that  it  served  as  a  storehouse  for  carbohydrates,  absorbed  as 
maltose  and  dextrose  from  the  intestines  through  the  portal  system  of 
veins,  and  stored  up  in  the  form  of  glycogen.  This  glycogen,  by  the 
metabolic  action  of  the  liver  cells,  may  be  again  converted  into  maltose 
as  occasion  demands,  and  be  given  off  into  the  general  circulation  for 
nutriment  to  the  muscles  and  other  structures  of  the  body.  Lately, 
however,  attempts  have  been  made  by  Silvestri  and  others  to  specialize 


44 


Physiology  of  Digestion. 


Fig.  15. — Diagram  to  Show  the  Relation  of  the  Lobes  of  the  Liver  to  Various 
Abdominal  Structures,  Indicated  by  Blood  Currents  in  the  Portal  Vein. 


Intestinal  Digestion.  45 

the  functions  of  the  right  and  left  lobe  of  the  liver.  As  has  been  known 
for  some  years,  the  right  lobe  of  the  liver  is  especially  affected  by  en- 
largement in  diabetes  (supposedly  a  pancreatic  disease);  while  in 
Banti's  disease,  and  other  splenomegalies,  the  left  lobe  is  more  particu- 
larly affected.  Silvestri  records  some  experiments  of  his  own,  and 
refers  to  others  by  Glenard  and  by  Serege,  which  tend  to  confirm  the 
idea  that  the  left  lobe  of  the  liver  is  intimately  connected  with  the 
stomach  and  the  spleen,  while  the  right  has  more  definite  relations 
with  the  pancreas  and  small  intestines.  Injections  of  staining  fluids 
into  the  spleen  invariably  produce  a  discolouration  in  the  liver  limited 
to  the  left  lobe;  while  similar  injections  into  the  superior  mesenteric 
radicles,  made  very  cautiously,  so  as  not  to  disturb  the  venous  current, 
always  stained  the  right  lobe  of  the  liver  much  more  than  the  left.  It 
is  to  be  hoped  that  some  practical  application  may  be  made  of  the  in- 
formation thus  gained. 

The  blood  pressure  in  the  portal  vein  and  in  the  liver  is  very  low, 
so  that  hemorrhage  from  the  liver  is  readily  controlled  by  pressure  or 
by  approximation  of  the  lips  of  the  wound  in  the  liver  by  sutures. 

The  internal  secretions  of  the  liver  and  pancreas  are  so  far  too 
little  understood  for  anything  very  definite  to  be  said  about  their 
physiological  activity.  The  enlargement  of  the  right  lobe  of  the  liver 
in  diabetes,  which  is  now  generally  considered  a  disease  of  the  pan- 
creas, has  already  been  alluded  to ;  and  the  recent  investigations  of 
Opie  make  it  evident  that  the  changes  in  the  pancreas  found  in  diabetes 
are  limited  almost  exclusively  to  the  islands  of  Langerhans. 

One  of  the  most  interesting  of  the  functions  connected  with  the 
complemental  metabolism  of  the  liver,  is  its  so-called  detoxicating 
power  over  certain  substances.  In  addition  to  its  influence  over 
certain  alkaloidal  and  mineral  poisons  (such  as  nicotine,  hyoscyamine, 
strychnine,  quinine,  atropine,  morphine,  antipyrine,  peptone,  and 
certain  toxines)  it  is  probable  from  some  recent  observations  of  Adami 
that  the  liver  exercises  a  somewhat  similar  detoxicating  power  over 
certain  forms  of  bacteria  themselves.  The  state  known  as  cholsemia, 
formerly  thought  to  be  caused  by  suppression  of  bile,  and  therefore 
analogous  to  uraemia,  has  been  observed  sufliciently  often  without 
obstruction  to  the  flow  of  the  bile  to  render  it  certain  that  it  is  caused 


46  Physiology  of  Digestion. 

by  an  auto-intoxication  from  changes  in  the  Hvcr  substance,  not  due 
to  the  damming  up  of  the  bihary  excretion.  For  ahhough  it  is  quite 
probable  that  this  latter  condition  will  in  most  instances  so  injure  the 
liver  cells  as  to  be  productive  of  choLTmia,  yet  other  factors  such  as 
biliarv  cirrhosis  may  be  equally  destructive  to  the  liver,  while  the 
excretion  of  bile  remains  unimpaired. 

The  Movements  of  the  Alimentary  Tract. — Chemical  digestion 
is  supplemented  by  movements  of  the  ahmentary  tract  which  provide 
mechanical  activity  necessary  for  the  following  purposes : — the  prepar- 
ation of  the  food  for  digestion  by  reducing  it  to  a  condition  of  fine  sub- 
division bv  means  of  the  movements  of  mastication;  the  intimate 
mixing  of  the  food  with  the  digestive  juices,  so  as  to  allow  of  these 
coming  in  contact  with  every  particle;  the  propulsion  of  the  food  from 
one  cavity  of  the  canal  to  the  next  as  soon  as  the  processes  of  digestion 
in  the  first  cavity  have  been  completed;  and  finally  the  rejection  and 
expulsion  from  the  body  of  the  indigestible  portions  of  the  food-stuffs, 
mixed  with  the  products  of  excretion  of  the  wall  of  the  alimentary 
canal  itself. 

Bearing  in  mind  the  uniform  character  of  the  primitive  digestive 
tube,  one  would  naturally  expect  to  find  similarity  in  structure  of  the 
walls  of  the  matured  gastro-intestinal  tube.  As  a  matter  of  fact, 
aside  from  variations  brought  about  from  modifications  of  structure 
and  specializations  of  function,  this  is  quite  the  case.  The  serosa, 
ori<^inally  a  com])letc  tunic,  becomes  incomplete  in  those  parts  of  the 
tube  where  but  little  motion  occurs,  as  in  the  duodenum,  ascending 
and  descending  colon.  The  mucosa,  primarily  of  uniform  thickness, 
becomes  well-developed  where  glandular  activity  is  greatest,  as  is 
illustrated  by  the  thickness  of  the  gastric,  duodenal,  and  jejunal 
mucosa,^  and  the  relative  thinness  of  that  in  the  remainder  of  the  tube. 
In  like  manner,  where  much  work  is  re(|uired,  the  muscular  tunic  is 
well  developed,  and,  in  certain  locations,  is  s])ecially  thickened  to  form 
sphincters.  Otherwise  it  is  thin  or  incomplete.  In  this  res])ect,  it 
may  be  compared  to  the  musculature  of  the  cardio-vascular  system. 
In  both  of  these  systems  the  circular  coat  is  developed  to  a  greater 
extent  than  the  longitudinal.  Unusual  muscular  effort  is  recjuired  of 
the  heart  and  of  the  stomach,  and  in  both  there  is  an  additional  layer 


Movements  of  the  Alimentary  Tract.  47 

of  obliquely  disposed  muscular  fibres.  Each  is  the  seat  of  rhythmical 
contractions.  In  the  aorta  and  large  arterial  trunks,  on  the  one  hand, 
and  in  the  duodenum  and  jejunum,  on  the  other,  the  muscular  tunics 
are  well-developed.  In  the  smaller  arteries  and  the  ileum  the  mus- 
cular tissue  gradually  diminishes  in  amount.  Muscular  activity  in 
the  veins  and  large  intestine  is  reduced  almost  to  a  minimum,  and  in 
both  the  musculature  is  either  poorly  or  imperfectly  developed.  To 
complete  the  simile,  it  may  be  mentioned  that  the  heart  and  stomach 
are  supplied  both  by  the  pneumogastric  and  by  the  sympathetic 
nerves,  whilst  the  blood-vessels  and  intestines  receive  their  innervation 
from  the  sympathetic  system.  Finally,  both  the  heart  and  the  stomach 
possess  intramural  ganglion-cells,  which  are  capable  of  producing 
spontaneous  contractions  of  these  organs,  even  when  they  are  liberated 
from  all  extrinsic  nervous  stimuli. 

Deglutition. — Mastication  reduces  solid  food  to  a  fine  pulp, 
which  the  tongue  forms  into  a  bolus.  A  peristaltic  contraction,  which 
consists  of  contraction  behind  the  mass  with  inhibition  and  relaxation 
in  front  of  it,  carries  the  bolus  down  to  the  stomach,  which  it  enters 
through  the  cardiac  orifice.  The  arrival  of  each  bolus  in  the  stomach 
can  be  detected  by  auscultating  the  back  of  a  patient  over  the  region 
of  the  cardiac  orifice,  which  corresponds  to  the  level  of  the  eleventh 
dorsal  vertebra.  A  gurgling  sound  is  heard  each  time  the  food  passes 
into  the  stomach. 

Movements  of  the  Stomach. — ^The  inhibition,  which  precedes 
the  bolus,  spreads  to  the  entire  gastric  wall,  so  that  the  latter  is  now  in 
a  passive  condition  for  reception  of  the  food.  The  food  accumulates 
first  in  the  fundus.  This  arrangement  is  readily  comprehended  since, 
as  was  shown  above,  there  is  never  any  empty  space  within  the  empty 
stomach,  its  cavity  being  only  as  large  as  its  contents. 

Although  "appetite-juice"  is  present  already  in  the  stomach,  yet 
the  latter  remains  in  a  passive  condition,  movements  appearing  only 
after  the  expiration  of  about  30  minutes  from  the  beginning  of  the 
meal.  During  this  time,  and  probably  longer,  salivary  digestion 
continues  undisturbed. 

The  food  ingested  remains  in  the  stomach  for  several  hours,  and 
is  ejected  at  intervals  into  the  duodenum.     Between  these  intervals. 


4.8  Physiology  of  Digestion. 

the  food  is  isolated  in  the  stomach  from  the  rest  of  the  alimentary 
tract  by  the  tonic  closure  of  the  sphincters  at  the  cardia  and  the  pylorus. 
The  portion  first  ingested,  lying  in  the  fundus,  is  marked  off  from  the 
antrum  by  a  strong  constriction  of  the  sphincter  antri  pylori.  The 
fundus  serves  as  a  reservoir  for  the  food,  and  is  subject  only  to  weak 
muscular  contractions.  The  pylorus,  on  the  contrary,  is  the  seat  of 
powerful  peristaltic  movements  by  means  of  which  the  food,  received 
from  the  passive  fundic  reservoir,  undergoes  thorough  churning. 

After  the  lapse  of  about  30  minutes,  at  regular  intervals,  small 
peristaltic  waves  begin  somewhat  to  the  cardiac  side  of  the  sphincter 
antri  pylori,  and  push  the  food,  detached  from  the  surface  of  the  mass 
in  the  fundus,  into  the  antrum  pylori,  made  a  blind  pouch  by  the  clo- 
sure of  the  pylorus.  The  antrum  pylori  now  becomes  lengthened,  and 
the  peristaltic  waves  here  increase  in  force  as  digestion  progresses. 
The  pylorus  remaining  closed,  the  food  cannot  escape,  and  is  squeezed 
back  through  its  sole  outlet,  namely,  the  opening  in  the  advancing 
peristaltic  rings,  thus  forming  an  axial  reflux  stream  toward  the 
cardiac  end.  This  cycle  is  repeated  again  and  again,  until  the  hard 
particles  of  food  are  broken  up,  brought  into  close  contact  with  the 
whole  of  the  pyloric  mucous  membrane,  and  thoroughly  mixed  with 
the  gastric  juice. 

At  varying  periods  the  pyloric  orifice  relaxes,  and  a  few  cubic 
centimetres  of  chyme  are  squirted,  with  considerable  force,  into  the 
duodenum.  These  periods  vary  according  to  the  character  of  the 
ingesta,  the  carbohydrates  leaving  the  stomach  first,  the  fats  next,  and 
the  protcids  last.  The  relaxation  of  the  pylorus  becomes  more  fre- 
quent as  digestion  progresses.  When  gastric  digestion  is  over,  the 
pylorus  may  open  to  permit  the  passage  of  undigested  food-particles. 

Opening  of  the  pylorus  is  brought  about  Ijy  the  presence  of  free 
acid  in  the  stomach.  In  this  way,  the  acid  chyme  is  discharged  into 
the  duodenum.  The  ])resence  of  acid  in  the  duodenum,  on  the 
contrary,  causes  contraction  of  the  pyloric  sphincter,  and  also  stimu- 
lates the  flow  of  tlic  alkahnc  ])ancrealic  sccrt'lion.  Neutrah/ation  of 
the  acid  in  the  duodenum  gradually  weakens  this  stimulus  to  ])yloric 
closure,  so  that  the  cycle  is  repeated  as  often  as  is  necessary  for  the 
emptying  of  the  stomach.     In  this  manner  the  intestine  is  charged 


Movements  of  the  Alimentary  Tract.  49 

with  food  very  gradually  by  the  stomach,  and  the  gastric  secretion, 
which  inhibits  the  action  of  intestinal  enzymes,  is  neutralized  in 
small  instalments. 

The  well-known  experiments  of  Kelling,  which  showed  that  filling 
of  the  duodenum  inhibited  contractions  of  the  stomach,  will  be  referred 
to  again  in  connection  with  gastro-jejunostomy  and  the  vicious  circle. 

It  is  not  very  accurately  known  how  long  food  should  remain  in 
the  stomach  after  ingestion,  nor  how  soon  the  stomach  should  be 
found  empty.  Several  hours  at  least  must  elapse;  but  the  motor 
power  of  the  stomach  is  said  to  be  delayed  if  salol  ingested  at  a  certain 
hour  cannot  be  detected  in  the  urine  as  salicyluric  acid  within  from 
forty  to  sixty  (at  most  seventy-five)  minutes  thereafter.  Salol  is  not 
absorbed  from  the  stomach,  but  by  means  of  an  alkaline  reaction  in 
the  duodenum.  When  a  drop  of  the  tincture  of  ferric  chloride  is 
added  to  urine  containing  salicyluric  acid,  a  dark  brownish  red  colour 
is  produced. 

Another  test  described  is  Klemperer's  oil  test,  from  seventy-five 
to  eighty  per  cent,  by  weight  of  the  ingested  oil  being  normally  dis- 
charged from  the  stomach  within  two  hours.  The  remaining  amount 
is  detected  by  removing  the  stomach  contents,  dissolving  them  in 
ether,  evapourating  the  solution,  and  weighing  the  residue  of  oil. 

A  few  words  may  be  devoted  in  this  place  to  the  mechanism  of 
vomiting,  a  symptom  which  is  of  such  common  occurrence  in  diseases 
of  the  upper  abdomen  as  to  warrant  the  surgeon's  particular  attention. 
Vomiting  is  produced  largely  by  contraction  of  the  abdominal  muscles, 
acting  upon  a  fixed  diaphragm,  the  stomach  being  compressed  be- 
tween the  two.  No  doubt  the  stomach  itself  contracts  spasmodically 
and  aids  in  the  ejection  of  the  food;  but  this  action  is  of  comparatively 
trivial  importance.  Sensory  impulses  to  the  gastric  mucosa  are  the 
chief  cause  of  vomiting,  although,  as  is  well  known,  certain  sights, 
certain  tastes,  and  irritation  of  the  uvula  or  the  pharynx  will  in  many 
persons  have  the  same  effect,  or  at  least  produce  nausea.  Sudden 
blockage  of  the  urinary  bladder  or  of  the  gall  bladder  by  a  calculus 
may  produce  the  same  result,  and  an  analogous  condition  is  described 
as  appendicular  colic. 

Movements  of  the  Small  Intestine. — The  small  intestine 
4 


50  Physiolog}'  of  Digestion. 

presents  two  kinds  of  mo\ements,  the  rh3^thmical  or  pendular,  which 
predominate,  and  the  peristaltic. 

In  the  pendular  movements,  the  coils  of  gut  sway  from  side  to  side, 
and,  by  contractions  of  the  circular  musculature,  split  the  column  of 
food  into  a  number  of  small  segments.  Soon  each  of  these  segments  is 
divided  in  half,  and  the  corresponding  halves  of  adjacent  segments 
re-unite.  This  process  is  repeated  again  and  again  at  the  rate  of 
seven  changes  a  minute.  Now  and  then  the  segments  are  carried 
onward  a  certain  distance  by  an  advancing  peristaltic  wave,  and 
collected  into  a  new  mass.  Rhythmical  segmentation  again  occurs  in 
this  new  situation.  In  this  way  the  food  is  thoroughly  mixed  with  the 
digestive  secretions,  and  every  particle  is  brought  into  intimate  con- 
tact with  the  absorptive  walls,  since  with  each  constriction  the  mucous 
membrane  is  plunged  directly  into  the  midst  of  the  small  segments. 

The  duodenal  sphincter  described  by  Ochsner  aids  materially  in 
mixing  the  chyme  just  received  from  the  stomach  with  the  duodenal 
secretions. 

The  peristaltic  movements  carry  the  unabsorbed  material  on- 
ward through  the  ileo-colic  sphincter  into  the  colon.  Regurgitation 
from  the  colon  into  the  ileum  is  prevented  by  the  tonic  contraction  of 
the  sphincter,  and  by  the  obliquity  of  the  ileo-ccecal  valve. 

Movements  of  the  Large  Intestine. — The  presence  of  the  semi- 
fluid contents  in  the  colon  starts  up  anti-peristaltic  waves;  these  begin 
near  the  junction  of  the  ascending  and  the  transverse  colon,  at  which 
point  there  is  a  physiological  muscular  contracture,  namely,  the 
caeco-colic  sphincter  (Mayo),  and  travel  slowly  toward  the  caecum, 
carrying  the  food  into  the  latter.  Regurgitation  being  impossible, 
part  of  the  food  must  slip  back  in  the  axis  of  the  tube,  with  the  same 
effect  as  occurs  in  the  pylorus.  Sacculation  of  the  large  intestine 
heightens  the  efficiency  of  these  movements.  By  these  churning 
movements,  the  contents  of  the  gut  are  mixed  thoroughly  with  the 
enzymes  of  the  small  intestine,  and  well  exposed  to  the  actively  ab- 
sorbing wall  of  the  large  intestine. 

Occasionally  a  true  ])cristahic  wave,  excited  l)y  distention  of  the 
caecum,  and  initiated  in  the  latter  organ,  carries  the  food  to  the  trans- 
verse colon.     This  wave,  however,  soon  dies  away,  and  most  of  the 


Movements  of  the  Alimentary  Tract.  51 

food  is  carried  csecalward  again  by  the  anti-peristalsis.  As  the  as- 
cending and  transverse  colons  are  gradually  filled  with  food  from  the 
ileum,  and  as  absorption  proceeds,  the  drier  portions  accumulate 
toward  the  splenic  flexure,  where  they  are  probably  separated  from 
the  more  fluid  parts  by  transverse  waves  of  constriction,  and  eventually 
collect  in  the  omega  loop  and  rectum  as  faeces. 

As  illustrative  of  the  interrelation  which  unites  the  digestive  pro- 
cesses in  an  orderly  series  of  successively  dependent  events.  Cannon 
sums  up  as  follows: 

"Chewing  food  that  is  relished  starts  the  flow  of  gastric  juice; 
gastric  juice  in  the  duodenum  is  the  cause  of  flow  of  bile  and  the  pan- 
creatic secretion;  the  pancreatic  secretion  in  turn  stimulates  the  forma- 
tion of  kinase,  which  activates  the  trypsinogen.  Similarly,  on  the 
motor  side  of  digestive  activities,  the  presence  of  material  in  the  stom- 
ach normally  starts  gastric  peristalsis;  acid  in  the  stomach  seems  to  be 
the  signal  for  the  opening  of  the  pylorus,  and  food  is  discharged; 
the  acid  food  in  the  duodenum  closes  the  pylorus  and  originates  seg- 
menting movements  to  churn  together  the  food,  pancreatic  juice,  and 
bile.  Peristalsis  carries  the  masses  forward;  now  in  new  situations 
their  presence  occasions  segmentation.  Finally,  the  remnant  of  the 
food  is  forced  from  the  ileum  into  the  colon;  and  each  new  accession 
to  the  accumulation  there,  is  followed  by  a  series  of  antiperistaltic 
waves  which  serve  to  abstract  still  further  the  valuable  constituents 
of  the  food.  When  a  certain  amount  of  useless  waste  has  gathered  in 
the  transverse  colon,  forward  peristaltic  waves  move  it  slowly  to  the 
rectum  to  be  discharged." 

Applied  Physiology. — Above,  we  have  given  a  brief  account  of 
the  secretory,  absorptive,  and  motor  activities  of  the  gastro-intestinal 
tract.  Let  us  see  what  practical  application  can  be  made  of  these 
facts.  In  other  words,  let  us  consider  briefly  the  subject  of  applied 
physiology. 

In  the  first  instance,  attention  has  already  been  directed  to  the 
importance  of  a  good  set  of  teeth.  Here,  at  the  very  entry  to  the 
gastro-intestinal  tract,  is  a  necessary  set  of  organs,  the  integrity  of  which 
is  so  essential  to  secure  the  best  results  from  digrestion.     Yet  too  often 


52  Physiology  of  Digestion. 

the  teeth  are  found  incomplete  in  numbers,  or  the  seat  of  varying 
degrees  of  decay.  There  is  small  wonder  for  this,  not  only  because  in 
the  human  race  the  teeth  are  undergoing  inherited  retrograde  pro- 
cesses due  to  unnatural  preparation  of  foods,  but  also  because  the 
dental  organs  are  subjected  to  the  action  of  the  oral  micro-organisms 
and  their  products,  as  lactic  acid.  Hence,  we  believe  the  teeth  should 
be  put  in,  and  kept  in,  the  best  condition  possible,  and,  for  the  sake  of 
emphasis,  we  should  like  to  haq^  longer  on  this  subject,  did  space 
permit. 

The  importance  of  sterilizing  the  mouth  as  far  as  possible,  and  the 
food  that  enters  it,  in  the  preliminary  preparations  for  operations  on 
the  stomach,  is  known  to  all  clinicians.  So,  too,  is  the  regard  for  the 
teeth  in  the  administration  of  hydrochloric  acid. 

The  stomach  is  worthy  of  more  attentive  care  than  it  usually 
gets.  It  is  not  just  to  dispose  of  it,  from  a  physiological  standpoint, 
lightly  as  a  mere  con\cnience  for  the  storage  of  food.  The  bladder 
and  the  rectum,  if  one  wish,  may  be  considered  as  convenient 
reservoirs,  but  it  must  be  remembered  that  these  organs  are  the 
terminals  for,  respectively,  the  urinary  and  the  digestive  apparatus, 
and  they  have  no  other  function  than  that  of  storage.  The  stomach, 
on  the  contrary,  is  at  the  very  portals  of  the  digestive  tube.  Not  only 
does  it  possess  definite  enzymotic  and  motor  functions,  but  it  is  also  a 
sensitive  organ,  endowed  with  selective  powers,  in  that  it  retains  whole- 
some food,  and  rejects  that  which  is  detrimental  or  injurious.  That 
the  stomach  is  one  of  the  most  sensitive  organs  in  the  body  cannot  be 
dcnicf],  and  it  is  c(|uall_\'  true  tliat  for  this  reason,  if  for  no  other,  it 
should  receive  much  consideration,  like  other  sensitive  things.  Sit- 
uated between  the  harmful  objects,  bacterial,  chemical,  and  physical, 
of  the  outside  world  and  the  delicate  intestines,  it  exercises  a  dis- 
tinct protecti\c  function  onxt  tlie  gut.  But  it  is  a  mistake  to  consider 
the  stomach,  or  any  other  i)arl  of  the  gastro-intestinal  tract,  as  a  sep- 
arate and  (h'stinct  entity.  Its  embryol()<rical  and  ])hysi()logical  rela- 
tions forbid  this,  and  sucli  is  c'(|uall}-  true  of  thi'  other  1)o(Hly  systems, 
such  as  the  nervous,  the  resj)iratory,  the  (  ire  ulatory,  and  the  urinary. 
The  intimate  functional  interrelations  of  llie  \arious  continuations  of 
the  gastro-intestinal  tract  have  been  remarked  upon,  and  these  inter- 


Applied  Physiolog}'.  53 

relations  operate  not  only  physiologically,  but  pathologically.  Were 
it  of  any  avail,  we  should  further  decry  abuse  of  the  stomach.  We 
demand,  however,  that  it  receive  consideration  solely  in  conjunction 
with  the  remainder  of  the  system  with  which  it  is  correlated. 

The  great  value  the  appetite  holds  in  the  interests  of  the  oeconomy 
cannot  be  overestimated.  Like  other  instincts,  it  cannot  be  neglected 
with  impunity.  To  restore  appetite  to  a  sickly  patient  is  to  confer 
upon  him  a  boon,  the  effects  of  which  are  far-reaching.  Not  the  least 
of  these  is  the  preservation  of  the  integrity  of  the  body  by  enriching 
the  blood,  thereby  increasing  the  protective  and  defensive  powers  of 
the  organism. 

In  the  first  instance,  regular  hours  for  the  intake  of  food  are  as  im- 
portant as  for  the  ejection  of  the  residue  from  the  body.  Food  should 
not  be  gobbled,  but  should  be  well  masticated,  and  eaten  with  dis- 
crimination and  care.  To  secure  the  best  results,  the  attention  should, 
as  far  as  possible,  be  concentrated  upon  the  process  of  ingestion.  The 
degree  of  enjoyment  with  which  food  is  taken  is  enhanced  by  the 
attractiveness  with  which  it  is  prepared.  Furthermore,  the  patient's 
tastes  should  receive  due  consideration. 

Even  should  these  conditions  be  fulfilled,  appetite,  and  conse- 
quently, appetite-juice,  may  still  be  absent.  In  this  instance,  feeding 
would  be  forced;  such  a  method  is  unnatural,  and  frequently  the 
stomach  rebels  against  it.  Here  the  aim  should  be  to  restore  the 
appetite,  for  this  means  copious  secretion  of  gastric  juice  to  act  upon 
the  ingesta.  It  would  be  wise  to  administer  a  cup  of  beef-broth 
shortly  before  meal-time,  for  both  the  water  and  the  beef-extract  con- 
tained therein  are  undoubtedly  strong  excitants  of  gastric  juice.  In 
the  same  way,  suitable  doses  of  hydrochloric  acid  may  be  carefully 
given,  since  acids  are  specific  stimuli  to  the  pancreas.  Further,  it  is 
often  beneficial  to  order  food  in  small  quantities,  frequently  repeated. 
By  this  method,  too  much  work  is  not  thrust  suddenly  upon  a  stomach 
impaired  in  its  activity,  and  appetite- juice,  which  is  so  powerful,  is 
repeatedly  called  forth. 

For  patients  in  whom  the  sense  of  taste  is  impaired,  bitters  may  be 
found  very  useful.  Not  only  do  these  stimulate  the  gustatory  cells  by 
means  of  contrast  to  pleasant  sensations,  but  also  they  produce  a 


54  Physiology  of  Digestion. 

certain  psychic  effect,  and  this,  in  turn,  indirectly  excites  a  physio- 
logical secretory  acti\ity. 

]Milk  is  a  rational  food  for  the  sick,  in  that  it  nourishes  the  organism 
with  the  least  degree  of  work  on  the  part  of  the  digestive  tract,  since  it 
provokes  the  weakest  gastric  juice  and  the  smallest  amount  of  pan- 
creatic fluid,  and  hence  gives  these  organs  rest.  This  rest  is  very 
desirable  when  the  gastric  glands  manifest  excessive  activity.  Alka- 
lies, also,  exert  an  inhibitory  influence  upon  the  digestive  glands.  The 
value  of  large  doses  of  sodium  bicarbonate  in  hyperchlorhydria  is  well 
known.  It  reduces  the  secretion  in  the  stomach,  and,  by  diminishing 
the  acidity  in  this  organ,  restrains  the  activity  of  the  pancreas.  On  the 
other  hand,  when  administered  in  small  doses,  this  salt,  theoretically 
from  a  chemical  standpoint,  cafls  forth  an  increased  output  of  hydro- 
chloric acid. 

Just  as  any  irritating  substance,  bacterial,  physical,  or  chemical, 
evokes  hypersecretion  from  any  mucous  or  serous  surface,  so  does  it 
from  the  very  extensive  mucous  membrane  of  the  gastro- intestinal 
tract.  This  overproduction  of  mucus  is  protective  in  nature,  in  that 
it  comes  from  the  surface  epithelium,  and  thus  wards  off  the  danger 
that  threatens  the  more  important  elements  of  the  mucous  membrane 
beneath.  Therefore,  many  forms  of  diarrhoea  are  expressive  of 
defence  on  the  part  of  the  organism. 

In  the  same  way,  defensive  activities  in  the  peritoneal  cavity  are 
carried  out  by  the  omentum  upon  the  serous  tunic  of  the  intestines. 
Thus,  according  to  Dickinson,  Buxton,  and  Torrey,  quoted  by  W.  J. 
Mayo,  the  omentum  is  a  most  important  agent  in  developing  phago- 
cytosis and  opsonins;  its  germinating  endothelium  is  constantly 
producing  lymphocytes  and  is  capable,  under  proju-r  stimulation,  of 
throwing  both  newly  formed  ])hag()cytes  and  those  called  from  a 
distance  into  germicidal  action.  This  wi])ing  ])rocess  is  greatly  aided 
by  the  vermicular  and  swaying  movements  of  the  intestines,  which,  in 
spite  of  gravity,  bring  all  parts  of  the  wall  of  the  small  gut  in  contact 
with  the  omentum,  the  e])iploic  tags  having  the  same  function  for  the 
more  fixed  large  intestine. 


Physiology  of  Digestion.  55 


REFERENCES. 

Adami:  Nothnagel's  Encyclopsedia,  Diseases  of  the  Liver,  Pancreas  and 
Suprarenal  Glands,  Philadelphia,  1903,  p.  414. 

Cannon:  Amer.  Jour.  Med.  Sc,  1906,  i,  563. 

Cannon  and  Blake:  Annals  of  Surgery,  1905,  i,  686. 

Cannon  and  Murphy:  Annals  of  Surgery,  1906,  i,  512. 

Howell:  Textbook  of  Physiology,  Philadelphia,  1905. 

Kelling:  Archiv.  f.  klin.  Chir.,  1900,  Ixii,  Nos.  i  and  2. 

Leven  and  Barret:  Presse  Med.,  1906,  xiv,  66. 

Mayo:  Amer.  Jour.  Med.  Sc,  1907,  i,  i. 

Ochsner:  Annals  of  Surgery,  1906,  i,  80. 

Opie:  Nothnagel's  Encyclopsedia,  Diseases  of  the  Liver,  Pancreas  and 
Suprarenal  Glands,  Philadelphia,  1903,  pp.  78  and  741. 

Pawlow:  The  Work  of  the  Digestive  Glands,  London,  1902. 

Silvestri:  Gazz.  d.  Ospedah  e  d.  Cliniche,  Milano,  1905,  xxvi,  570. 

Starling:  Advances  in  the  Physiology  of  Digestion,  Chicago,  1906. 


CHAPTER  III. 
GENERAL  DIAGNOSTIC  CONSIDERATIONS. 

Although  the  diagnosis  of  each  surgical  affection  discussed  is 
treated  in  considerable  detail  in  the  special  chapter  devoted  to  the 
subject,  yet  it  is  convenient  in  this  place  to  dwell  upon  certain 
general  considerations  in  regard  to  diagnosis,  which  are  of  nearly 
equal  importance  in  every  surgical  affection  of  the  upper  abdomen. 
And  we  do  this  with  the  greater  confidence,  because  we  fear  that  some 
surgeons  who  are  called  in  merely  as  consultants  may  be  tempted  to 
take  the  diagnosis  of  the  malady  ready  made  from  the  physician,  and 
to  regard  the  operative  treatment  of  their  patients  as  the  only  province 
particularly  belonging  to  surgery.  This  attitude  of  mind,  we  venture 
to  suggest,  is  not  only  derogatory  to  the  profession  of  surgery,  but 
inimical  to  the  ultimate  interests  of  both  patient  and  surgeon.  While 
we  realize  that  all  progressive  physicians  are  now  anxious  to  have  a 
surgical  consultation  in  the  case  of  most  of  the  diseases  of  the  upper 
abdomen  which  do  not  readily  yield  to  hygienic  and  dietetic  measures, 
we  are  also  well  aware  that  they  are  loath  to  consult  a  surgeon  who  can 
offer  no  other  advice  than  to  adopt  the  plan  which  is  colloquially 
referred  to  as  "taking  off  the  lid."  It  is  admitted  by  all  that  it  is 
desirable  for  the  surgeon  to  have  a  thorough  appreciation  of  the  nat- 
ural course  of  the  morbid  process  going  on  within  the  patient,  in  other 
words,  that  he  must  be  well  grounded  in  the  ])atli()logy  of  these  diseases; 
but  it  will  be  impossible  for  him  to  give  an  intelligent  opinion  on  such 
questions,  unless  he  is  first  able  to  determine  what  the  disease  really  is. 
To  jnit  it  in  the  plainest  terms,  a  consultant  must  be  able  to  render  an 
opinion  which  will  be  worth  the  asking;  and  unless  his  diagnostic 
acumen  is  of  the  highest,  physicians  will  soon  perceive  that  it  is  for 
their  patients'  interest  to  go  elsewhere. 

Anamnesis.  —  In  every  case,  there  is  no  siirci"  foiindalion  on  which 

5(^ 


Inspection — Palpation.  57 

to  lay  the  facts  which  go  to  make  up  a  correct  diagnosis,  than  an  ac- 
curate and  complete  history  of  the  patient's  past  medical  life  and 
present  complaint.  It  is  exceptional  indeed  for  such  a  history  not  to 
point  the  way  toward  further  investigations  which  will  reveal  the 
true  malady.  It  may  seem  tedious  and  commonplace  to  both  patients 
and  surgeon  to  lay  stress  on  data  such  as  age,  occupation,  general 
habits  of  diet,  previous  illnesses,  etc. ;  but  neglect  of  one  minor  detail 
may  distort  the  clinical  picture,  and  lead  the  diagnostician  very  seri- 
ously astray. 

In  addition  to  the  patient's  history,  the  careful  diagnostician  will 
take  advantage  of  every  fact  that  may  be  learned  from  a  complete 
physical  examination,  including  Inspection,  Palpation,  Percussion, 
and  Auscultation;  Mensuration  also  may  be  of  value  in  a  few  instances. 

Inspection. — The  patient  should  lie  fiat  on  the  back,  with  the 
entire  abdomen  and  lower  thorax  bared,  and  in  a  good  light.  The 
general  contour  of  the  abdomen  should  be  noted,  whether  fat  or 
emaciated,  tense  or  flaccid;  together  with  the  presence  or  absence  of 
localized  bulging,  of  peristaltic  waves,  of  scars  from  previous  opera- 
tions, etc.  Attention  should  be  directed  to  the  character  of  the 
breathing,  whether  it  be  natural  or  affected  by  the  surgeon's  examina- 
tion; whether  it  be  shallow  and  rapid,  and  confined  to  the  chest,  as  is 
often  the  case  in  the  presence  of  peritonitis;  or  whether  the  normal 
full  abdominal  breathing  be  present,  which  usually  denotes  the  absence 
of  any  painful  abdominal  condition;  or  irregular,  short,  spasmodic 
breathing,  which  sometimes  indicates  implication  of  the  diaphragm; 
or  possibly  the  long,  sighing  respirations,  as  of  "air  hunger,"  often 
seen  in  cases  of  internal  hemorrhage.  The  appearance  of  the  costal 
angle  should  be  noted,  as  well  as  any  undue  bulging  or  depression  of 
the  pit  of  the  stomach.  The  configuration  of  the  thorax,  as  indicative 
of  tight  lacing,  may  prove  of  diagnostic  value  in  certain  affections  of 
the  liver  and  stomach. 

Palpation. — This  is  the  most  valuable  of  all  means  of  physical 
examination  at  the  command  of  the  surgeon.  It  should  never  be 
omitted,  and  should  always  follow  inspection.  In  order  to  obtain  the 
greatest  number  of  diagnostic  points  by  its  means,  it  is  important  to 
have  the  abdominal  muscles  as  relaxed  as  possible.     This  relaxation 


58  General  Diagnostic  Considerations. 

is  best  secured  by  having  the  patient's  head  and  shoulders  slightly 
elevated,  and  by  flexing  the  thighs  on  the  abdomen.  The  thighs 
should  be  passively,  not  actively,  flexed;  so  that  it  is  best  either  to 
support  the  knees  by  placing  a  pillow  beneath  them,  or  to  have  the 
thighs  flexed  so  far  that  the  soles  of  the  feet  will  rest  comfortably  on 
the  bed  or  couch  on  which  the  patient  lies. 

The  hands  of  the  diagnostician  should  always  be  warm,  so  that 
no  reflex  spasm  of  the  abdominal  muscles  will  be  caused  by  chilling 
from  contact  of  the  hands.  It  should  be  an  invariable  rule  to  begin 
the  palpation  in  some  presumably  healthy  region  of  the  abdomen,  in 
order  to  accustom  the  patient  to  the  palpating  hand  before  the  dis- 
eased area  is  reached,  and  to  ascertain,  if  possible,  the  natural  con- 
dition of  the  belly  wall  in  health.  The  patient's  attention  may  be 
diverted  from  the  local  examination  by  conversation.  The  entire 
abdomen  should  be  thoroughly  examined  by  palpation,  the  hand 
being  allowed  to  slide  over  its  surface  rather  than  being  raised  and 
again  laid  on  the  skin,  for  fear  of  producing  involuntary  contraction 
of  the  abdominal  muscles  from  the  new  contact. 

The  degree  of  rigidity  in  all  portions  of  the  abdomen  must  be 
noted.  Attentive  examination  should  be  made  of  any  tumescence 
detected,  noting  especially  its  location,  its  consistence,  its  density,  its 
fixity,  its  general  conformation;  the  presence  or  absence  of  movement 
during  respiration;  its  mobihty,  and  if  any,  in  what  directions;  and 
finally  its  relation  to  surrounding  structures  must  be  considered. 

The  degree  of  tenderness  present  in  the  various  portions  of  the 
abdomen  must  be  noted,  together  with  the  amount  of  pressure  neces- 
sary to  provoke  it.  The  degree  of  tenderness  to  pressure,  combined 
with  the  rigidity  of  the  abdominal  wall  at  the  site  of  the  tenderness, 
will  often  be  of  marked  diagnostic  significance. 

The  presence  or  absence  of  a  succussion  s])lash  in  the  stomach 
may  be  determined  by  means  of  pal])ali()n.  This  s])lash  is  very 
significanl  in  cases  of  gastreclasis  if  found  in  certain  relation  with 
meals,  as  it  will  indicate  decided  lack  of  gastric  motility. 

Percussion. — This  is  of  the  utmost  value  in  ma])])ing  out  the  re- 
lation of  the  various  abdominal  organs.  J I  will  re\eal  the  size  and 
position  of  the  li\-er,  the  j)Osilion  of  tlie  colon,  of  llu'  stomach,  and  of  the 


'    Percussion — Auscultation.  59 

spleen;  the  presence  or  absence  of  hepatic  dullness;  the  presence  or 
absence  of  free  fluid  in  the  abdominal  cavity,  etc.  In  many  instances 
much  additional  information  is  to  be  gained  by  distending  the  stomach 
with  air  or  liquid,  so  that  its  position  and  extent  can  be  definitely 
determined.  The  air  should  be  forced  into  the  stomach  by  means  of 
a  hand  bulb  on  the  stomach  tube;  we  do  not  approve  of  the  use  of  an 
effervescing  powder  for  inflation  of  the  stomach,  because  this  latter 
method  cannot  be  controlled,  and  may  lead  to  serious  results;  more- 
over, it  certainly  causes  much  more  discomfort  to  the  patient  than  does 
the  use  of  a  stomach  tube,  by  means  of  which  the  amount  of  air  intro- 
duced can  be  accurately  regulated.  The  patient  himself  is  the  best 
judge  of  the  amount  of  air  to  be  introduced;  and  the  least  discomfort 
on  his  part  should  make  the  surgeon  desist  from  introducing  more  air. 
The  same  is  true  for  the  introduction  of  fluids,  either  for  the  purpose 
of  distending  the  stomach,  or  for  washing  it  out.  If  any  doubt  as  to 
the  outlines  of  the  stomach  remains  after  distention  with  air  or  fluid 
has  been  tried,  it  is  at  times  advisable  to  inflate  the  colon  with  air 
while  the  stomach  is  distended  with  fluid.  In  this  way  percussion 
will  reveal  their  relative  positions  with  great  accuracy,  and  may  throw 
much  light  on  an  obscure  condition,  or  reveal  the  exact  location  of 
any  tumor  that  may  be  present. 

Auscultation. — Auscultation  alone,  or  in  combination  with  per- 
cussion, may  be  of  decided  value  in  the  diagnosis  of  diseases  of  the 
upper  abdomen.  It  is  well  known  that  the  time  when  food  or  liquids 
enter  the  stomach  can  be  detected  by  auscultating  the  thorax  about 
three  inches  below  the  angle  of  the  left  scapula.  It  is  well  for  the 
inexperienced  to  listen  to  the  normal  sound  in  healthy  individuals, 
many  times,  before  attempting  to  diagnosticate  a  lesion  of  the  oesoph- 
agus or  cardia  by  this  method.  The  amphoric,  rushing  sound  is 
heard  from  three  to  seven  seconds  after  the  act  of  swallowing;  if 
delayed  more  than  ten  seconds,  it  is  safe  to  infer  that  some  ob- 
struction, spasmodic  or  organic,  is  present. 

Auscultatory  percussion  is  sometimes  of  aid  in  determining  the 
exact  outlines  of  a  distended  stomach ;  the  stethoscope  is  placed  over 
the  air-containing  organ  to  be  outlined,  and  an  assistant  gently  per- 
cusses from  surrounding   structures    toward  that    over  which  the 


6o  General  Diao-nostic  Considerations. 


to 


stethoscope  is  placed;  as  the  border  of  the  distended  stomach  is 
crossed,  the  change  of  note  is  very  perceptible  through  the  stethoscope. 
In  a  similar  manner,  the  coin  test  may  be  used  in  an  air- containing 
cavity,  such  as  the  stomach,  or  a  subphrenic  abscess  in  direct  con- 
nection with  the  gastro-intestinal  tract. 

Mensuration. — This  is  occasionally  useful  to  record  from  time 
to  time  variations  in  the  amount  of  abdominal  distention;  to  note 
increase  of  ascitic  fluid;  to  compare  one  side  of  the  abdomen  with 
the  other,  etc. 

General  Health. — In  deciding  for  or  against  an  operation  it  is 
of  course  requisite  for  the  surgeon  to  take  into  consideration  the  general 
health  of  the  patient.  The  state  of  the  heart,  the  lungs,  and  the 
vascular  system  should  be  attentively  studied;  and  careful  examina- 
tion should  be  made  of  the  amount  and  quality  of  the  urine  excreted. 
^Myocardial  disease  will  be  in  general  more  of  a  contraindication  to 
operation  than  will  a  well  compensated  valvular  lesion.  The  gastric 
and  intestinal  manifestations  of  nephritis  should  be  kept  constantly  in 
mind. 

Gastric  Analysis. — The  analysis  of  the  stomach  contents,  and 
the  determination  of  the  motility  of  the  organ,  are  at  times  a  con- 
siderable help  in  arriving  at  a  correct  diagnosis.  Sometimes  ad- 
vantage may  be  taken  of  the  opportune  vomiting  of  the  patient,  who 
thus  places  at  the  disposal  of  the  examiner  sufficient  material  for 
analysis  and  study.  Usually,  however,  it  is  necessary  to  give  a  "test 
meal,"  and  to  withdraw  this  Ijy  means  of  the  stomach  tube  in  a  speci- 
fied time.  The  test  meal  we  employ  consists  of  one  piece  or  slice  of 
Zwiebach  and  a  small  cup  of  weak  tea,  given  on  a  fasting  stomach. 
The  stomach  is  then  emptied  by  the  stomach  tube  one  hour  after  the 
ingestion  of  the  meal.  We  also  think  it  of  considerable  value  to  test 
the  gastric  motility  by  evacuating  the  stomach  six  hours  after  the  in- 
gestion of  an  ordinary  full  meal;  if  the  motility  is  normal,  there  should 
be  practically  no  residue  after  this  la])se  of  time. 

This,  of  course,  is  not  the  place  to  describe  the  various  methods  of 
gastric  analysis.  They  arc  fully  discussed  in  many  special  treatises, 
as  well  as  in  most  text  books  on  medicine. 

Passing  the  Stomach  Tube. — The  stomach  tul)e  should  l)c  in 


The  Stomach  Tube.  6i 

good  condition,  and  its  surface  should  be  perfectly  smooth.  As  soon 
as  the  surface  begins  to  crack,  the  tube  should  be  discarded.  The 
tube  should  be  cleansed  and  boiled  after  using;  it  should  then  be 
dried  in  the  air  and  put  away.  It  is  not  necessary  to  boil  it  again  just 
before  using,  though  it  is  often  desirable  to  do  so;  but  repeated  boiling 
soon  destroys  it.  When  the  stomach  is  to  be  inflated  with  air,  the 
tube  should  have  a  hand  bulb  attached  to  it  about  25  cm.  beyond  the 
"tooth  mark."  The  valve  on  the  bulb  should  be  kept  in  good  work- 
ing order.  Air  will  escape  spontaneously  from  the  inflated  stomach, 
through  the  tube,  as  soon  as  the  bulb  is  detached.  To  withdraw  fluid 
from  the  stomach,  syphonage  will  usually  suffice;  but  by  reversing 
the  hand  bulb,  the  apparatus  may  be  converted  into  a  suction 
pump. 

If  the  patient  is  strong  enough,  it  is  more  convenient  to  pass  the 
■tube  while  he  is  in  a  sitting  posture;  if  necessary,  however,  it  is  quite 
possible  to  introduce  it  while  he  is  lying  down.  In  most  cases  sufi&- 
cient  lubrication  will  be  afforded  by  the  mucus  in  the  pharynx  and 
oesophagus,  the  tube  being  dipped  into  lukewarm  water  just  before 
being  introduced.  Oils  or  other  lubricants  are  usually  very  dis- 
agreeable to  the  patient.  A  mouth  gag  need  not  be  employed  except 
in  children  and  unconscious  or  refractory  patients. 

The  surgeon,  facing  the  patient,  and  having  his  own  clothing,  as 
well  as  that  of  the  patient,  suitably  protected,  takes  the  stomach  tube, 
about  six  inches  from  its  end,  in  his  right  hand,  holding  it  as  a  pen; 
then,  directing  the  patient  to  open  the  mouth  widely,  he  passes  the 
index  finger  of  his  left  hand  into  the  patient's  mouth.  In  the  exces- 
sively nervous  the  uvula  and  palatal  arches  may  be  cocainized.  With 
the  left  forefinger  as  a  guide,  and  drawing  forward  on  the  base  of  the 
tongue,  the  stomach  tube  is  gently,  but  firmly  passed  back  until  its 
end  touches  the  posterior  wall  of  the  pharynx.  By  then  guiding  its 
point  downward  with  the  left  index  finger,  it  is  gradually  fed  onward 
by  the  right  hand;  and  by  keeping  it  close  against  the  posterior 
pharyngeal  wall,  it  will  glide  into  the  oesophagus.  At  this  moment  the 
patient,  if  the  stomach  tube  is  being  passed  for  the  first  time,  usually 
gags,  and  feels  as  though  he  were  smothering.  If  he  is  assured, 
however,  that  all  is  going  well,  his  momentary  distress  is  quieted,  and 


62  General  Diagnostic  Considerations. 

he  will  find  himself  able  to  breathe  comfortably  in  spite  of  the  presence 
of  the  tube  in  his  gullet.  Then,  as  the  patient  makes  slight  efforts  at 
swallowing,  the  tube  is  allowed  to  glide  down  into  the  stomach,  until 
the  tooth  mark  reaches  the  dental  margin.  It  is  very  seldom  that 
force  is  required,  when  once  the  end  of  the  tube  has  become  fairly  en- 
gaged in  the  oesophagus;  and  if  the  surgeon  is  gentle  and  patient  in 
his  manipulations,  the  patient  wiU  find  that  the  ordeal  of  having  a 
stomach  tube  passed  is  by  no  means  unbearable;  indeed  that  it  is 
much  less  disturbing  in  reality  than  in  anticipation. 

After  a  patient  has  had  a  tube  passed  once  or  twice,  no  guiding 
finger  will  be  necessary,  and  the  patient  very  often  will  prefer  to  pass 
it  himself,  instead  of  having  this  done  by  the  surgeon.  Those  who 
are  in  the  habit  of  having  stomach  tubes  passed  experience  very  httle 
more  discomfort  than  is  felt  in  passing  a  soft  rubber  catheter  through 
a  normal  urethra. 

Lavage  of  the  Stomach. — Tepid  water,  either  alone,  or  with  a 
httle  bicarbonate  of  soda  added,  is  the  hquid  that  is  usually  employed. 
For  patients  with  marked  fermentative  changes,  a  weak  solution  of 
permanganate  of  potassium  is  useful.  Not  more  than  ten  or  twelve 
ounces  should  be  passed  into  the  stomach  at  first.  This  should  be 
done  very  gradually,  with  the  funnel  of  the  tube  very  little  higher  than 
the  level  of  the  stomach.  The  feehng  of  beginning  discomfort  on  the 
patient's  part  is  the  safest  indication  of  the  amount  to  be  introduced 
at  one  time.  In  unconscious  patients,  and  in  those  with  marked 
disease  of  the  stomach,  only  a  very  small  quantity  should  be  used  at 
any  one  time;  and  even  greater  gentleness  than  usual  should  be 
employed,  on  account  of  the  danger  of  producing  rupture  of  the 
stomach  (see  p.  327).  After  the  proper  amount  has  been  introduced 
into  the  stomach,  the  funnel  should  be  lowered  and  tlien  inverted  over 
a  waste  bucket,  and  the  gastric  contents  syphoned  off,  the  j)rocess 
being  repeated  until  the  fluid  returns  clear. 

Skiagraphy  in  Diagnosis  of  Lesions  of  the  Upper  Abdomen. — 
In  cases  where  the  ordinary  methods  of  ])hysical  examination  leave 
the  diagnosis  in  doubt,  or  where  it  is  desired  to  obtain  confirmation  of 
a  diagnosis,  the  Roentgen,  or  X-rays,  often  will  be  of  material  assist- 
ance.    There  is  but  one  ohjcclion  to   the  use  of   thr  X my  in   this 


X-Ray  Examination.  63 

connection,  and  that  is  the  fact  that  it  is  useless  unless  employed  by  an 
expert  in  this  particular  branch  of  X-ray  work.  The  technique 
employed  is  so  complicated,  and  demands  such  close  study,  that  a 
description  of  it  would  be  entirely  out  of  place  here;  but  it  is  necessary 
for  the  clinician  who  is  to  take  advantage  of  work  being  done  by  ex- 
pert Roentgenologists  to  realize  what  aid  may  be  given  them,  and 
what  preliminary  preparation  of  the  patient  is  necessary  to  render  the 
skiagraphic  examination  of  value. 

When  possible,  the  patient's  gastro-intestinal  tract  should  be  thor- 
oughly emptied.  This  is  best  accomphshed  by  means  of  a  purge  and 
abstinence  from  food.  Liquids  may  be  administered  if  necessary, 
but  even  this  diet  should  be  limited  to  broths,  albumen  water,  etc. 
Milk  is  apt  to  form  curds,  and  these  may  be  very  misleading,  especially 
in  an  examination  of  the  stomach  for  malignant  disease.  The  patient 
should  be  prepared  to  remove  the  clothing  from  the  abdomen.  It  is 
generally  better  to  remove  all  clothing,  substituting  a  dressing  gown 
without  buttons,  or  a  sheet  which  will  cover  the  entire  body. 

More  information  of  value  can  probably  be  obtained  from  a 
skiagraphic  examination  of  the  stomach,  than  from  that  of  any  other 
viscus  in  the  upper  abdomen.  This  organ  is  studied  after  it  has  been 
rendered  transparent  by  inflating  it  with  air,  or  after  rendering  it 
opaque  by  the  ingestion  of  some  bismuth  preparation.  Air,  as  a  rule, 
does  not  distribute  itself  well  in  the  stomach,  and  is  really  important 
only  in  the  study  of  the  fundus  or  "upper  pole." 

The  stomach  normally,  and  except  when  adherent  to  surrounding 
structures,  is  distinctly  movable  and  changes  its  contour  and  position 
with  the  position  of  the  patient's  body.  The  posture  of  the  patient, 
therefore,  should  vary  according  to  the  portion  of  the  stomach  which 
it  is  desired  to  examine.  The  standing  posture  generally  is  the  most 
useful.  In  this  position  the  axis  of  the  stomach  is  almost  vertical  and 
the  organ  is  situated  almost  entirely  to  the  left  of  the  median  line.  The 
lower  one-third  is  more  or  less  horizontal,  but  the  upper  two-thirds 
are  nearly  vertical  in  this  position.  The  upper  pole  normally  rests 
against  the  diaphragm;  the  lower  pole  in  the  standing  position  reaches 
nearly  to  the  umbilicus  and  is  little  lower  than  the  pylorus.  In  gastro- 
ptosis  the  lower  pole  of  the  stomach  may  reach  any  distance  below 


64  General  Diagnostic  Considerations. 

this  level.  In  the  dorsal  decubitus  the  greater  portion  of  the  stomach 
occupies  the  left  h}'pochondrium.  Most  text-book  illustrations  are 
made  with  the  viscera  in  position  as  seen  on  the  operating  or  dissecting 
table,  and  hence  do  not  give  an  accurate  idea  of  the  position  assumed 
by  the  stomach  when  the  patient  is  erect. 

A  portion  of  bismuth  mixture  may  be  administered  with  the  patient 
standing.  By  fluoroscopic  examination  a  swallow  of  liquid  food  may 
be  seen  to  enter  the  stomach  completely  in  about  seven  seconds 
(Pfahler.)  A  delay  usually  means  some  constriction  at  the  cardiac 
orifice,  either  spasmodic  or  organic.  If  organic,  solid  portions  of  food, 
or  bismuth  capsules  or  pills,  will  be  retained  a  longer  time,  according 
to  their  size,  the  calibre  of  the  constriction,  and  the  degree  of  solubility 
of  the  ingested  material.  If  due  to  malignant  change,  the  constric- 
tion usually  can  be  outlined  in  the  gaseous  field  which  occupies  the 
upper  portion  of  the  stomach  when  the  patient  is  in  a  standing 
posture. 

When  the  portion  of  bismuth  mixture  swallowed  has  passed  the 
cardia,  the  bolus  can  be  seen  to  enter  the  stomach  and  gradually  to 
separate  the  walls  of  that  organ  as  it  works  its  way  to  the  lower  pole. 
A  new  growth  or  constriction  in  the  wall  of  the  stomach,  even  though 
small,  will  cause  the  food  to  change  its  normal  course.  In  an  hour- 
glass constriction,  the  separation  of  the  food  in  the  upper  pole  from 
that  in  the  lower  may  be  clearly  seen.  It  is  generally  requisite  to 
have  the  stomach  well  filled  with  bismuth  mixture  to  insure  a  correct 
diagnosis  of  hourglass  deformity.  At  times  a  growth  in  the  stomach 
can  be  detected  by  the  separation  of  the  food  in  the  stomach  from  the 
gas  in  the  colon,  thus  showing  that  something  abnormal  is  situated 
along  the  greater  curvature  of  the  stomacli. 

New  growths  in  llie  lower  pok'  are  recognized  partially  by  the 
outline  of  the  bismuth  food;  by  the  interference  with  the  peristaltic 
waves,  which  normally  arc  active  in  this  portion;  and  at  times  a 
growth  will  be  indicated  by  the  immobihty  of  the  lower  pole,  sug- 
gesting perigastric  adhesions. 

Carcinoma  near  the  pylorus  will  show  an  irregularity  in  the  out- 
line of  the  bismuth  mixture.  Normally  the  position  of  the  pylorus 
is  shown  by  a  relatively  lrans])arcnt  s])a(C  between  the  food  in  the 


X-Ray  Examination.  65 

stomach  and  that  in  the  first  part  of  the  duodenum.  When  infikrated 
with  carcinoma,  this  area  of  transparency  is  lost  or  distorted.  If 
stenosis  exist,  food  will  be  retained  an  abnormally  long  time  on  the 
proximal  side  of  this  point.  If,  on  the  other  hand,  the  pylorus  is 
rendered  rigid  by  the  disease  but  remains  patulous,  as  at  times  occurs, 
the  food  may  be  seen  to  pass  out  of  the  stomach  nearly  as  fast  as  it 
enters  at  the  cardiac  orifice. 

Although  the  factors  mentioned  above  may  be  determined  by  the 
use  of  the  fluoroscopic  screen,  yet  much  confirmatory  evidence, 
and  practically  all  details,  must  be  obtained  from  the  skiagraphic 
plate.  Gastroptosis  can  be  accurately  recorded  upon  the  plate;  but 
such  facts  as  the  tone  of  the  gastric  wall,  the  depth  of  the  peristaltic 
contractions,  and  the  effect  of  the  contractions  of  the  muscles  of  the 
abdominal  wall,  and  of  the  movements  of  the  diaphragm,  can  only  be 
observed  on  the  screen. 

The  duodenum  curves  around  the  head  of  the  pancreas,  and  by 
observing  the  outline  of  the  former,  some  information  may  be  obtained 
as  to  the  probable  size  of  the  head  of  the  latter.  A  constriction  of  the 
duodenum  may  at  times  be  shown  by  a  dilatation  of  the  portion  pre- 
ceding the  stricture. 

The  liver  usually  can  be  outlined,  but  the  X-ray  will  not  be  of 
much  value  in  this  determination,  as  other  means  at  our  disposal  are 
just  as  accurate  and  more  readily  applied.  The  presence  of  gall- 
stones can  be  shown  occasionally,  but  their  density  is  so  slight  that 
failure  to  demonstrate  their  presence  will  by  no  means  indicate  their 
absence.  Large  amounts  of  adipose  tissue  between  the  gall-bladder 
and  plate,  or  a  large  collection  of  bile  in  the  bladder  very  often  will 
render  impossible  the  demonstration  of  gall-stones.  As  a  rule,  the 
information  concerning  the  gall-bladder  obtained  by  means  of  the 
X-ray  can  be  used  only  as  confirmatory  and  never  as  negative  evi- 
dence. 

The  spleen  usually  can  be  outlined  by  means  of  the  rays,  but  so 
far  they  have  been  used  very  little  for  this  purpose. 

A  subphrenic  collection  of  pus  usually  will  cause  a  change  in  the 
normal  contour  of  the  diaphragm  on  the  affected  side.     The  dia- 
phragm will  be  pushed  upward  and  its  normal  excursion  will  be  dis- 
5 


66  General  Diagnostic  Considerations. 

tinctly  lessened.     When  the  abscess  is  secondary  to  thoracic  disease, 
this  fact  usually  can  be  demonstrated. 

Diaphragmatic  hernia  can  be  recognized  by  a  displacement  of 
the  lung  tissue  or  heart  by  a  transparent  body.  In  a  few  instances 
it  has  been  possible  to  distinguish  by  means  of  the  X-rays  between 
diaphragmatic  hernia  and  eventration  of  the  diaphragm. 

REFERENCES. 

Cannon  and  Murphy:  Annals  of  Surgery,  1906,  i,  512. 
Dalton  and  Raid:  Trans.  Clin.  Soc.  London,  1905,  xxxviii,  122. 
Hulst:  Archives  of  Physiological  Therapy,  Boston,  1906,  iii,  i. 
Leven  and  Barret:   Presse  Med.,  1906,  xiv,  66. 
Worden:   Trans.  Coll.  Phys.  Phila.,  1906,  xxviii,  151. 


CHAPTER  IV. 

BENIGN  DISEASES  OF  THE    STOMACH  AND    DUODENUM. 
GASTRIC  ULCER. 

It  is  usual  to  classify  gastric  ulcer  as  acute  and  chronic; 
but  as  one  form  grades  into  the  other  by  almost  imperceptible 
degrees,  and  as  it  is  frequently  impossible  to  tell  during  life  to 
which  of  the  classes  the  ulcers  in  question  belong,  such  distinctions 
seem  to  be  a  refinement,  and  of  greater  pathological  than  clinical 
interest.  It  would  be  better  to  classify  ulcers  of  the  stomach  as 
"open,"  and  "healed  or  healing,"  for  thus  the  surgeon  would  be  in  a 
position  to  express  readily  the  difference  between  the  two  main  varie- 
ties which  are  distinguished  by  their  symptoms.  As  will  be  seen 
later  it  is  really  the  state  of  the  ulcers  in  regard  to  the  stage  of  their 
cicatrization  that  determines  the  symptomatology,  and  not  mere 
duration.  An  ulcer  which  has  existed  for  twenty  years  will  still  be 
"acute"  if  it  is  unhealed,  and  is  liable  to  hemorrhage  or  perforation; 
while  one  which  in  the  space  of  a  few  months  has  passed  through  the 
stages  of  granulation,  cicatrization,  and  contraction  will  become 
chronic  as  soon  as  the  cicatrizing  and  contracting  process  has  exceeded 
the  ulcerating  feature  of  the  lesion.  Of  course,  certain  ulcers  of  the 
stomach  may  be  ulcerating  in  one  portion  of  their  surface,  while  they 
are  cicatrizing  and  contracting  in  another;  but  even  if  this  be  the  case, 
the  latter  features  usually  will  overshadow  the  former,  and  the  ulcer 
is  to  all  intents  and  purposes  a  healing  ulcer. 

.Etiology. — Gastric  ulcer  is  one  of  those  diseases  for  which  no 
satisfactory  cause  has  yet  been  found.  After  discussing  with  more  or 
less  approval  the  various  theories  advanced  by  ardent  investigators, 
most  authors  are  content  to  return  to  the  statement  that  no  one  cause 
is  always  operative,  and  that  the  essential  conditions  for  the  production 
and  perpetuation  of  an  ulcer  of  the  stomach  are,  first,  some  lesion  to 

67 


68         Benign  Diseases  of  the  Stomach  and  Duodenum. 


*& 


the  gastric  mucosa,  and,  second,  impaired  resistive  power  of  the 
mucosa  itself.  And  then  we  are  reminded  that  this  reduces  the 
question  to  Hunter's  original  theory  of  a  "vital  principle"  which 
enabled  the  gastric  mucosa,  while  living,  to  resist  the  disintegrating 
action  of  the  gastric  juice.  Different  writers  have  cited  different 
examples  of  the  lesions,  and  of  the  cause  of  the  impaired  resistive 
power. 

It  is  probable  that  a  more  intimate  knowledge  of  the  correct  action 
of  the  various  organs  associated  with  metabohsm,  brought  about  by 
the  continued  study  of  the  normal  physiology  of  these  structures  and 
the  changes  shown  by  the  li\'ing  pathology  as  seen  on  the  operating 
table,  will  allow  us  to  state  definitely,  in  the  near  future,  the  exact 
aetiological  factors  of  gastric  and  duodenal  ulcers.  At  present  we  can 
only  theorize,  accepting  for  the  time  being  those  theories  which  seem 
to  be  most  thoroughly  substantiated  by  our  findings  at  the  bedside,  at 
the  operating  table,  and  in  the  laboratory. 

As  to  the  frequency  of  gastric  ulcer,  no  very  satisfactory  statistics 
exist;  the  most  frequently  quoted  figures  are  those  of  Brinton  and  of 
Welch,  which  tend  to  show  that  gastric  ulcer  is  found  in  five  per 
cent,  of  mankind.  At  the  present  time  writers  are  inclined  to  consider 
it  an  even  more  frequent  disease. 

Predisposing  Causes: — Climate. — It  has  been  proved  by  statistics 
that  geographical  location  has  a  decided  influence  on  the  frequency  of 
gastric  ulcer.  Welch  gives  the  statistics  of  various  different  cities, 
and  Douglas  concludes  that  it  is  more  common  in  northern  than  in 
southern  latitudes. 

Age. — When  we  consider  statistics  as  to  age  we  arc  at  once  con- 
fronted with  the  difficulty  that  it  is  almost  impossible  to  tell  how 
long  an  ulcer  has  existed,  or,  in  otlier  words,  at  what  age  it  lirst 
made  its  appearance.  In  most  autopsy  reports  no  differentiation  is 
made  between  open  and  healed  or  healing  ulcers;  nor  is  it  always  pos- 
sible to  obtain  a  clinical  history  of  the  patient  which  would  throw  light 
upon  the  length  of  time  symptoms  of  gastric  ulcer  had  been  present. 
The  statistics  of  Brinton  include  all  stages  of  ulcer  found  at  autopsies. 
Welch  collected  607  cases  of  o])en  ulcer  and  found  that  $;^  (5.43  per 
cent.)  were  in  patients  less  than  twenty  years  of  age;   226  (37.2  per 


^Etiology  of  Gastric  Ulcer.  69 

cent.)  were  in  those  between  the  ages  of  twenty  and  forty;  222  (36.5 
per  cent.)  were  inpatients  between  the  ages  of  forty  and  sixty;  and  126 
(20.7  per  cent.)  only,  in  patients  over  sixty  years  of  age.  The  largest 
number  of  cases  (119)  in  any  one  decade  was  found  between  the  ages 
of  twenty  and  thirty.  One  case  was  that  of  a  child  less  than  ten  years 
old;  there  was  one  patient  over  one  hundred  years  of  age.  Bechtold 
has  recorded  the  case  of  a  girl  of  five  years  who  died  from  perforation 
of  a  gastric  ulcer ;  and  Parkinson  has  recorded  a  similar  condition  in 
a  child  two  years  of  age.  It  is  probable  that  these  ulcers  in  children 
are  closely  related  to  the  toxaemias  of  infancy  (see  p.  71).^  Van 
Valzah  and  Nisbet  conclude  that  one-half  of  the  cases  have  their 
beginning  between  the  ages  of  twenty  and  thirty,  and  about  four- fifths 
between  the  ages  of  twenty  and  forty  years. 

Sex. — It  is  generally  admitted  that  females  are  more  liable  to  gas- 
tric ulcer  than  are  m'ales.  Recent  surgical  experience  seems  to  show 
that  females  are,  moreover,  peculiarly  liable  to  suffer  from  the  acute 
symptoms  of  ulcer,  whereas  males  do  not,  so  frequently,  present 
symptoms  of  sufficient  seriousness  to  require  treatment  until  the  ulcer 
has  reached  the  cicatrizing  stage  which  compels  them  to  seek  relief 
from  pyloric  or  other  form  of  obstruction.  In  a  large  number  of  cases 
it  is  accurate  enough  to  say,  with  Welch,  that  females  form  60  per  cent, 
and  males  40  per  cent,  of  the  total. 

Occupation,  especially  among  females,  has  long  been  considered 
a  predisposing  cause  of  gastric  ulcer.  The  sedentary  habits  of  seam- 
stresses, dressmakers,  governesses,  and  other  women  with  similar  oc- 
cupations are  in  themselves  sufficient  materially  to  reduce  the  resistive 
power  of  the  gastric  walls  and  thus  render  the  mucosa  more  liable  to 
the  deleterious  effects  of  exciting  causes  which  in  healthy  individuals 
would  be  trivial. 

Other  Diseases  in  the  upper  abdomen  may  act  as  predisposing 
causes  of  gastric  ulcer.     Adhesions  between  the  biliary  apparatus 

^  G.  K.  Paterson,  in  reporting  an  operation  by  Caird  for  perforation  of  a  gastric 
iilcer  in  a  boy  of  12  years,  collects  15  others  in  children  under  14  years  of  age.  The  only 
operation  besides  Caird's,  was  recorded  by  Cheyne  and  Wilbe;  both  patients  recovered. 
All  the  other  perforations  were  verified  by  autopsy,  the  diagnosis  not  having  been 
made  in  most  during  life.  The  youngest  child  was  45  hours  old,  the  next  youngest 
was  two  months  old,  and  the  third  was  one  year. 


yo  Benign  Diseases  of  the  Stomach  and  Duodenum. 

and  the  stomach  are  generally  recognized  as  all-important  factors. 
These  adhesions  impair  the  gastric  motility,  disturb  the  gastric  circu- 
lation, and  in  these  ways  produce  an  area  of  lessened  resistance  which 
predisposes  to  ulceration.  We  have  seen  many  cases  in  which  this 
course  of  events  was  too  clear  to  be  denied.  These  secondary  gastric 
changes  often  cause  more  discomfort  than  the  original  disease. 

Rasmussen  has  suggested  that  tight  lacing  might  act  as  a  pre- 
disposing factor  in  the  causation  of  gastric  ulcer,  by  impairing  the 
circulation  and  motility  of  the  stomach  either  directly  or  by  first  pro- 
ducing a  "corset  liver."  This  was  apparently  the  case  in  the  patient 
whose  stomach  is  pictured  in  Fig.  23. 

Typhoid  ulcers  of  the  stomach  are  rare.  According  to  Gandy, 
such  cases  have  been  recorded  by  Papellier,  Jones,  Poisson,  Millard, 
and  Chauffard.  Proskauer  found  t\"phoid  ulcers  of  the  stomach, 
duodenum,  and  entire  intestinal  tract  at  autopsy  on  a  boy  g  years 
of  age,  who  had  been  operated  on  for  diffuse  peritonitis  of  undis- 
covered origin.     There  were  no  perforations  found. 

Syphilitic  and  tuberculous  ulcers  of  the  stomach  are  considered  at 
pp.  238,  245. 

An  impaired  condition  of  the  blood  such  as  is  found  in  the  ancemias 
has,  by  many  authorities,  been  considered  the  chief  contributing  cause 
of  ulcer  of  the  stomach. 

The  foregoing  predisposing  aetiological  factors  of  gastric  ulcer  act 
almost  entirely  by  impairing  the  natural  resistance  of  the  gastric  mucosa 
to  any  injuring  force,  no  matter  what  the  nature  of  the  latter  may  be. 

Exciting  Causes:— Trauma  by  ingested  food  is  considered  by 
many  to  be  the  main  exciting  cause  of  gastric  ulcer.  Acute  dis- 
tention of  the  stomach,  by  mechanically  producing  slight  ruptures  of 
the  mucosa,  may  act  as  a  mechanical  cause  of  gastric  ulcer  (Strass- 
mann,  MouUin).  From  the  evidence  whicli  has  been  accumulated  in 
recent  years,  it  seems  to  us  that  it  is  most  rational  to  accc])t  some 
form  of  toxcemia  as  the  exciting  cause  of  gastric  ulcer. 

The  theory  of  the  toxaemic  origin  of  gastric  ulcers  has  much  in 
its  favour.  It  was  elabourated  Ijy  Nauwerck,  has  been  su])])ortcd  by 
Diculafoy,  and  forms  the  subject  of  the  thesis  of  Gandy,  which  should 
be  consulted  by  all  who  are  interested.     Gandy  shows  that  in  prac- 


^Etiology  of  Gastric  Ulcer.  71 

tically  all  toxaemias  there  are  gastro- intestinal  ulcers,  and  that  in 
practically  all  cases  of  gastro-intestinal  ulceration  there  is  present 
some  form  of  toxsemia.  He  points  out  the  remarkable  similarity 
which  exists  between  the  ulcers  of  toxaemias  (including  the  intestinal 
ulcers  met  with  in  cases  of  burns),  and  the  so-called  simple  ulcers  of 
the  stomach.  They  are  alike  in  latency,  in  tendency  to  hemorrhage 
and  perforation,  and  in  their  acute  formation.  They  are  also  alike 
in  their  clinical  course:  the  earliest  stage  in  all  is  ecchymosis;  then 
hemorrhagic  infarct;  slough;  hemorrhagic  erosion;  "exulceratio 
simplex"  of  mucosa;  true  ulceration  with  hemorrhagic  borders; 
and  finally  perforating  ulcer,  or  chronic  ulcer  with  thickened  border, 
or  a  cicatrix.  He  was  able  to  trace  these  forms  in  (i)  burns;  (2)  in- 
fantile diseases  (melsena);  (3)  infections  (erysipelas,  septicaemia, 
pyaemia,  local  septic  infections,. variola,  scarlatina,  purpura,  puerperal 
infection,  infections  of  uterus  and  adnexa;  infections  of  genito- 
urinary apparatus,  strangulated  hernia,  biliary  infections,  pneumonia, 
pleural  infections,  phthisis,  diphtheria,  articular  rheumatism,  rabies, 
tetanus,  cholera,  dysentery,  typhoid  fever,  etc.).  In  infantile  diseases, 
burns,  and  typhoid  fever  he  was  able  to  find  pathological  changes 
representing  each  of  the  degrees  above  mentioned,  beginning  with 
ecchymosis,  and  ending  with  perforation.  He  remarks,  further,  that 
observers  have  for  many  years  noted  all  the  above  lesions  in  other 
parts  of  the  stomach  or  digestive  tube,  in  cases  of  gastric  ulcer,  but 
do  not  seem  to  have  appreciated  the  fact  that  they  probably  represented 
earlier  stages  of  the  same  process.  In  patients  with  gastric  ulcer  it  is 
probable  that  the  toxaemia  is  always  of  infectious  origin;  and  previous 
lesions  of  the  liver  and  kidneys,  by  increasing  the  toxaemia,  act  as 
predisposing  causes. 

Quite  recently  somewhat  similar  views  have  been  expressed  by 
Hort,  who  evidently  has  worked  in  ignorance  of  the  labours  of  Gandy 
and  of  Dieulafoy.  With  the  advantages  which  the  most  recent  re- 
searches in  chemical  biology  have  placed  in  the  physician's  power, 
Hort  has  been  able  to  carry  the  theory  of  the  toxaemic  origin  of  gastric 
and  duodenal  ulcers  one  step  further  than  hitherto.  He  thinks 
gastric  ulcer,  including,  as  above  stated,  ecchymosis,  erosion,  and 
actual  ulcer,  is  due  to  a  general  blood  disease,  in  the  nature  of  a 


72         Benign  Diseases  of  the  Stomach  and  Duodenum. 

toxaemia,  the  local  effects  in  the  stomach  being  due  to  the  production 
of  haemorrhagins,  which  eat  through  the  endothehal  hning  of  the 
blood  vessels,  and  secondly  to  mucolysins,  which  destroy  the  gastric 
mucosa.  Ecchymosis,  recognized  as  the  first  stage  in  the  production 
of  a  gastric  ulcer,  is  produced  by  the  hsmorrhagins  alone;  when  the 
mucolysins  also  act,  an  erosion  is  produced,  and  in  time  a  fully  de- 
veloped ulcer  will  be  found,  unless  antibodies  are  formed  by  the 
organism  to  hold  these  cytolysins  in  check.  These  cytolysins  affect 
the  gastric  mucosa  through  either  the  lymph  stream,  "constantly 
flooding  epithelial  cells  with  the  specific  toxins  (mucolysins)  or  from 
escaped  blood  charged  with  the  same  bodies  (haemorrhagins,  muco- 
lysins)." Hort  concludes  (i)  that  no  other  theory  as  yet  put  forward 
brings  into  line  such  apparently  incongruous  manifestations  as  ulcer 
without  hemorrhage,  hemorrhage  without  ulcer,  perforation  without 
hemorrhage,  etc.;  (2)  that  it  is  useless  to  expect  to  find  in  the  dead 
house  conclusive  evidence  of  cause  and  effect  of  hemorrhage  and  ulcer 
beyond  that  of  extravasation;  (3)  that  the  present  day  medical  treat- 
ment of  the  conditions  must  be  modified;  and  (4)  that  the  use  of 
surgery  in  combating  a  profound  toxaemia  must  be  carefully  restricted. 
The  proofs  he  promises  to  offer  in  a  further  communication  consist  of: 
I.  Direct  evidence  of  cytolysis  in  these  affections  shown  by  (a)  blood 
examinations,  (b)  remarkable  results  of  treatment  by  serum  and 
vaccines  in  his  own  hands.  II.  Collateral  evidence  (A)  of  cytolysis  in 
other  similar  diseases,  shown  by  (a)  blood  examinations,  (b)  serum 
and  vaccine  therapy  for  such  diseases  in  the  hands  of  others  as  well  as 
in  his  own  hands;  and  (B)  of  cytolysis  in  the  lower  animals  shown 
(a)  by  producing  these  lesions,  and  (b)  by  curing  them  by  serum 
and  vaccine  therapy.  Were  this  theory  of  the  toxaemic  origin  of 
gastric  ulcer  to  be  proved  correct,  it  would  certainly  simplify  our 
ideas  as  to  the  pathology  of  this  affection,  as  well  as  afford  an  explana- 
tion for  many  obscure  gastric  and  intestinal  hemorrhages. 

John  B.  Roberts  has  collected  sixteen  cases  (including  two  in 
his  own  practice)  in  which  gastric  lesions  followed  soon  after,  and 
were  apparently  caused  by,  operations  on  the  urinary  bladder.  All 
such  observations,  it  seems  to  us,  lend  support  to  the  theory  of  the 
toxemic  origin  of  gastric  ulcer. 


Clinical  Pathology  of  Gastric  Ulcer.  73 

Clinical  Pathology. — Gastric  ulcers  are  more  often  multiple  than 
has  usually  been  supposed.  Brinton  reported  multiple  ulcers  in  only 
21  per  cent,  of  cases;  but  it  has  been  found,  when  special  attention  is 
directed  to  this  point  in  post-mortem  examinations,  that  multiple 
ulcers  are  found  much  more  frequently  than  this;  and  certainly  at 
operation  it  is  much  more  usual  to  find  the  evidences  of  several  ulcers 
than  it  is  to  find  only  one.  Indeed,  we  think  it  is  not  incorrect  to 
state  that  ulcers  are  more  often  multiple  than  single  in  all  patients, 
although  it  may  be  one  particular  ulcer  that  gives  rise  to  prominent 
symptoms. 

The  site  of  the  ulcers  is  usually  toward  the  lesser  curvature,  and 
much  more  often  in  the  pyloric  region  of  the  stomach  than  elsewhere. 
Ulcers  are  also  more  frequent  on  the  posterior  than  on  the  anterior 
wall  of  the  stomach.  The  ulcer  may  be  latent,  especially  if  on  the 
lesser  curvature.  Savariaud  says  that  latent  ulcers  occur  in  one-fifth 
of  all  cases  of  gastric  ulcer;  and,  as  Robson  and  Moynihan  suggest, 
the  situation  of  the  ulcer  is  probably  a  sufficient  explanation  for  its 
latency.  The  frequency  of  involvement  of  the  pyloric  portion  is 
likewise  explicable  on  mechanical  grounds,  as  it  is  this  portion  of  the 
stomach  that  is  most  actively  in  motion  during  digestion,  and  is  there- 
fore most  liable  to  traumatism  from  the  contained  food.  By  the  same 
reason  is  explained  the  occurrence  of  duodenal  ulcer,  which  is  more 
often  found  to  be  coincident  with  gastric  ulcer  than  existing  alone. 
The  existence  of  similar  ulcers  on  the  anterior  and  posterior  gastric 
walls  (the  so-called  "kissing  ulcer")  is  more  probably  due  to  similar 
relations  to  the  blood  supply  than  to  any  fancied  infection  of  another 
portion  of  the  stomach  by  an  existing  ulcer. 

The  course  pursued  by  gastric  ulcers  does  not  differ  materially 
from  that  of  ulcers  of  any  other  region  of  the  body  exposed  to  such 
constant  traumatism.  If  the  ulcer  is  sufficiently  severe  in  character 
to  compel  attention  and  procure  appropriate  medical  treatment  in  its 
early  stages,  it  is  prone  to  heal  by  cicatrization  and  contraction  with- 
out much  puckering  of  the  gastric  surface,  and  does  not  as  a  rule  give 
rise  to  further  trouble  later  in  life.  The  small  white  scars  left  by  such 
ulcers  are  seen  by  the  surgeon  constantly  in  his  operations.  If,  how- 
ever, the  symptoms  at  the  onset  of  the  ulceration  are  not  very  acute, 


74         Benign  Diseases  of  the  Stomach  and  Duodenum. 

suitable  treatment  is  often  neglected,  and  the  patient  suffers  from 
various  grades  of  gastric  indigestion,  since  various  factors  tend  to 
prevent  the  spontaneous  healing  of  gastric  ulcers.  Ulcers  of  the 
stomach  have  been  compared  to  leg  ulcers,  and  the  resemblance  is  in 
many  respects  close.  Both  develope  insidiously,  and  are  endured  by 
the  patient  because  not  very  acute  in  character,  and  because  proper 
treatment  would  necessitate  interruption  of  the  usual  activities  of 
life.  If  a  leg  ulcer,  when  in  an  early  stage,  could  be  treated  by  rest  in 
bed,  and  if  such  treatment  could  be  persisted  in  until  a  cure  was  really 
produced,  recurrence  of  the  lesion  would  be  unusual.  The  same  may 
be  said  of  the  gastric  ulcer.  But,  as  Robson  and  Moynihan  have  re- 
marked, the  acute  pain  in  both  cases  ceases  as  soon  as  the  cicatrizing 
process  has  fairly  commenced;  and  as  soon  as  the  acute  symptoms 
subside,  the  patients  want  to  be  up  and  about  again,  with  the  result 
that  the  ulcer,  whether  of  the  leg  or  the  stomach,  is  never  really  cured. 
So  that  even  simple  ulcers,  if  treatment  be  not  carried  to  proper  length, 
will  be  prone  to  become  chronic,  and  to  resemble  in  type  those  ulcers 
which  were  only  sub-acute  in  type  at  their  origin,  and  which  therefore 
received  no  treatment  at  all.  The  constant  use  to  which  the  stomach 
must  be  put,  the  periodical  outpouring  of  the  irritating  acid  secretion 
of  the  gastric  mucosa,  and  the  recurring  mechanical  traumatism  of  the 
food,  all  tend  to  prevent  healing  of  an  ulcer  which  has  once  formed. 
Add  to  these  factors  which  are  present  even  in  healthy  individuals, 
those  which  are  operative  in  an  anaemic  or  sickly  person,  and  the 
j)robability  of  the  spontaneous  healing  of  a  gastric  ulcer  becomes  even 
more  remote.  The  mild  sepsis,  both  of  the  mouth  and  the  stomach, 
on  which  Mayo  Robson  lays  such  well  descr\'ed  stress,  finds  here  its 
field  of  activity.  The  longer  such  lesions  remain  unhealed,  the  longer 
time  will  be  reriuired  for  their  repair  by  medical  means;  recurrence 
after  medical  "cure"  is  frecjuent,  and  even  surgical  ojjcralions  are  not 
sure  preventatives  of  recurrence,  since  they  at  most  place  the  patient 
in  the  same  condition  with  respect  to  future  gastric  ulcers  as  he  was 
before  the  dcvelopement  of  the  ulcers  for  which  the  operation  was 
done. 

When  an  ulcer  has  once  formed  in  the  stomach  it  is  liable  either 
to  become  callous,  or  to  give  rise  to  the  acute  complications  of  hemor- 


Clinical  Pathology  of  Gastric  Ulcer.  75 

rhage  or  perforation.  As  far  as  duration  alone  is  concerned,  it  soon 
becomes  a  chronic  ulcer  whatever  its  special  characteristics  may  be. 
But  it  is  not  always  possible  merely  by  looking  at  an  ulcer  to  deter- 
mine its  duration;  and  where  several  ulcers  coexist,  it  is  often  manifest 
that  some  of  them  are  much  more  recent  than  others.  Nor  does  the 
duration  of  the  clinical  symptoms  always  decide  upon  the  age  of  the 
ulcer.  It  is  frequently  impossible  to  tell  which  one  of  several  ulcers 
has  caused  symptoms  the  longest.  An  ulcer  may  have  been  latent  for 
a  considerable  period  before  producing  symptoms,  or  may  have  be- 
come quiescent  some  time  since,  and  the  recent  symptoms  may  have 
been  caused  by  a  more  recently  developed  ulcer,  or  by  one  which, 
though  present  for  a  long  time,  only  recently  has  become  symptom 
producing.  As  a  rule,  however,  it  is  safe  to  assume  that  an  ulcer  with 
callous  edges,  and  with  its  margin  shelving,  rather  than  punched  out, 
is  an  ulcer  of  long  duration — possibly  ten  to  fifteen  years;  while  an 
ulcer  resembling  in  character  the  "erosion"  of  Dieulafoy  is  mani- 
festly of  quite  recent  formation.  The  "acute  round  ulcer,"  which 
appears  cut  out  of  the  stomach  wall,  is  of  indefinite  duration,  and 
while  we  can  say  that  it  probably  has  not  existed  so  long  as  an  ulcer 
with  callous  margins,  we  cannot  be  certain,  except  from  the  patient's 
clinical  history,  that  it  has  existed  longer  than  a  few  months  or  even 
weeks. 

This  punched  out  ulcer  is  still  actively  ulcerating,  and  has  not  as  a 
rule  commenced  to  granulate  to  any  appreciable  degree.  Its  base  is 
usually  formed  by  the  muscularis  of  the  stomach  wall,  and  as  it  is 
unprotected  by  granulation  tissue,  it  is  much  more  prone  to  perforate 
than  is  an  ulcer  of  the  callous  type.  And  when  perforation  takes  place 
in  this  punched  out  ulcer,  the  peritoneal  cavity  is  usually  at  once  in- 
volved, and  the  stomach  contents  escape  into  the  general  belly  cavity 
unchecked  by  adhesions.  A  callous  ulcer,  on  the  other  hand,  has  its 
base  covered  with  granulations.  Its  base,  but  more  especially  its 
margin,  shows  the  result  of  long-standing  reactive  inflammation,  and 
the  stomach  walls  are  correspondingly  thickened.  Hence  perforation 
in  this  type  of  ulcer  is  much  more  unusual  than  in  the  acute  round 
ulcer,  and  when  perforation  does  occur,  the  base  of  the  ulcer  is  fre- 
quently adherent  to  some  neighbouring  organ,  particularly  the  liver 


76         Benign  Diseases  of  the  Stomach  and  Duodenum. 

or  the  pancreas,  or  is  so  protected  by  adhesions  to  the  intestinal  tract 
or  the  omentum,  that  general  infection  of  the  peritoneum  rarely 
occurs  at  once.  The  formation  of  a  subphrenic  or  subhepatic  abscess, 
or  an  empyema  of  the  lesser  peritoneal  cavity,  very  frequently  in  these 
cases  precedes  generalized  peritoneal  infection,  and  renders  possible 
the  application  of  surgical  measures  in  time  to  prevent  the  latter  com- 
plication. 

The  erosions  seem  more  apt  than  other  forms  of  ulceration  to  give 
rise  to  sudden  and  overwhelming  hemorrhage,  appearing  as  the  first 
symptom  of  gastric  ulceration,  and  at  times  leading  to  rapid  death. 
The  bleeding  is  in  the  nature  of  a  general  venous  ooze.  The  punched 
out  ulcer  gives  rise  to  acute  and  recurring  hemorrhages,  by  ulcerating 
into  a  blood  vessel.  The  bleeding  is  as  a  rule  safely  checked  by  med- 
ical means,  but  operation  is  indicated  to  prevent  a  recurrence  of  this 
alarming  feature.  The  callous  ulcer  is  the  variety  which  produces, 
more  frequently  than  any  other,  those  occult  hemorrhages  which  in- 
duce the  severe  anaemia  not  unfrequently  encountered  in  this  disease. 

In  form,  the  punched  out  ulcer  is  generally  well  described  by  its 
usual  name  of  round  ulcer,  while  the  callous  ulcer  is  more  or  less  ir- 
regular in  outline,  sometimes  appearing  as  if  formed  by  the  coalescence 
of  several  smaller  ulcers,  and  usually  having  its  longest  axis  transverse 
to  the  long  axis  of  the  stomach.  It  is  this  form  of  ulcer  which  is 
chicJly  j)roductivc  of  gastric  distortions,  such  as  pyloric  stenosis  and 
hourglass  stomach. 

Symptoms. — The  symptoms  of  gastric  ulcer  may  be  conveniently 
studied  as  those  present  in  a  patient  with  open  ulcer ;  those  occurring 
when  hemorrhage  is  a  marked  symptom;  those  of  perforation;  and 
finally  those  due  to  contraction  and  adhesions  of  the  ulcer. 

Open  ulcer,  which,  as  has  already  l)cen  remarked,  is  a  preferable 
term  to  acute  ulcer,  is  that  form  of  tlic  affection  which  of  all  others  is 
characterized  by  pain.  It  should  not,  however,  be  taken  for  granted 
that  no  ulcer  exists  when  pain  is  absent.  As  previously  noted,  an 
open  ulcer  may  remain  latent  until  its  presence  is  announced  by 
hemorrhage  or  perforation.  lUil  the  ])ain  when  it  does  occur  is  suf- 
ficiently characteristic  to  make  it  necessary  for  the  ])hysician  to  give 
it  his  careful  attention.     When  the  stomach  is  empty  there  is  rarely 


Symptomatology  of  Gastric  Ulcer.  ^"^ 

any  pain,  but  very  soon,  sometimes  immediately  after  food  is  swal- 
lowed, a  soreness  or  a  sharp  stabbing  pain  will  arise  at  some  well- 
defined  spot  in  the  epigastrium;  and  this  soreness  will  persist,  and 
probably  grow  continually  worse,  until  the  stomach  is  emptied,  either 
by  vomiting  or  by  the  discharge  of  its  contents  into  the  duodenum. 

It  is  impossible  to  decide  from  the  site  of  pain  or  from  the  time 
after  the  ingestion  of  food  at  which  it  first  appears,  in  precisely  what 
region  of  the  stomach  the  ulcer  is  situated  or  the  condition  of  the 
ulcer.  The  cause  of  the  pain  is  at  present  a  much  disputed  question. 
Although  the  nerve  supply  of  the  stomach  is  largely  derived  from  the 
pneumogastric  nerve,  which  carries  both  sensory  and  motor  fibres, 
many  investigators  and  operators  claim  that  there  is  no  sensation  in 
the  stomach  itself.  Mansell  Moullin  asserts  that  the  pain  is  not  due 
to  irritation  of  sensory  nerves  in  the  stomach,  because,  he  claims, 
it  has  none.  The  pain  is  caused,  he  says,  by  irritation  of  the  sensory 
nerves  of  the  parietal  peritoneum  by  means  of  adhesions,  by  contact 
or  merely  by  excessive  peristalsis.  If  his  assertions  are  true,  the  theory 
that  an  excess  of  hydrochloric  acid  present  in  the  stomach  causes  the 
pain  which  immediately  foUows  the  ingestion  of  food,  must  be  aban- 
doned. Clinical  experience  teaches  that  pain  which  occurs  imme- 
diately after  the  ingestion  of  food  is  a  symptom  of  a  more  serious  con- 
dition than  is  pain  which  is  slightly  delayed. 

Accompanying  the  pain,  and  usually  also  present  in  the  intervals 
between  food,  when  pain  is  often  absent,  will  be  found  a  more  or 
less  well-defined  and  constantly  located  area  of  tenderness  to  pressure. 
This  is  usually  in  the  costal  angle,  a  little  to  the  right  of  the  median 
line,  as  it  is  under  this  portion  of  the  abdominal  wall  that  the  pyloric 
area  of  the  stomach  is  most  frequently  found.  If  the  tender  spot, 
which  varies  in  size  from  a  half  inch  to  two  or  three  inches  in  diameter, 
is  found  further  to  the  left,  it  is  probable  that  the  ulcer  is  not  close  to 
the  pylorus ;  while  if  it  is  toward  the  right  costal  margin,  the  lesion  is 
very  likely  to  be  in  the  duodenum. 

The  pain  is  not  unfrequently  referred  to  some  other  region  as  well 
as  to  the  epigastrium,  particularly  to  the  left  h\"pochondrium  and 
neighbourhood  of  the  left  scapula.  But  more  frequently  it  is  the  ten- 
derness that  is  referred,  particularly  to  the  dorsal  region.  Peculiarly 
characteristic  is  a  tender  spot  to  the  left,  more  rarely  to  the  right,  of  the 


78         Benign  Diseases  of  the  Stomach  and  Duodenum. 

last  two  dorsal  vertebrae.  This  sign  is  supposed  to  be  more  often 
due  to  an  ulcer  upon  the  posterior  than  to  one  upon  the  anterior  wall 
of  the  stomach.  Pain  and  tenderness  which  are  referred  are  much 
less  usual  in  these  open  ulcers  than  in  those  w^hich  have  formed  ad- 
hesions in  the  course  of  their  cicatrization  and  contraction. 

Vomiting,  next  to  pain,  is  the  most  constant  symptom  of  gastric 
ulcer.  In  open  ulcers  vomiting  is  often  induced  by  the  pain  which 
the  ingested  food  causes,  and  some  patients  will  voluntarily  produce 
emesis,  by  gagging  themselves,  merely  to  be  reheved  of  their  gastric 
distress.  The  act  of  vomiting  may  occur  spontaneously  soon  after  a 
meal  is  taken,  but  when  it  is  a  constant  feature  of  the  disease,  it  does 
not  occur  as  a  rule  until  at  least  a  half  hour  or  an  hour  after  eating. 
The  vomited  matter  is  notably  acid  and  malodorous,  and  is  commonly 
streaked  with  blood.  The  vomiting  is  usually  not  repeated  until 
after  the  next  meal.  Many  patients  will  have  nausea,  but  no  vomit- 
ing. 

Hcematemesis  may  occur  independently  of  the  vomiting  after 
meals  at  any  time  that  the  ulcer  invades  a  blood  vessel.  Profuse  and 
prostrating  hemorrhage  may  occur  as  the  first  stage  of  gastric  disease, 
and  is  then  often  due  to  one  form  of  the  erosions  described  by  Dieu- 
lafoy,  being  a  venous  flow  whose  precise  origin  is  rarely  discoverable 
either  at  operation  or  autopsy.  The  possibihty  of  there  being  vari- 
cosities in  the  stomach  or  oesophagus  should  not  be  overlooked. 
When  the  hemorrhage  is  in  more  moderate  amount,  but  repeated  at 
intervals  of  days,  weeks,  or  months,  it  is  especially  significant  of  the 
acute  round  ulcer  (open  ulcer).  Any  sudden  increase  in  arterial 
tension  may  give  rise  to  such  a  hemorrhage.  The  process  of  digestion, 
with  the  accompanying  increased  activity  and  hypergemia  of  the 
stomach,  is  naturally  the  most  frequent  cause;  but  sudden  excitement, 
straining  at  stool,  and  vomiting,  will  all  act  in  the  same  way.  It  is  rare 
at  night  when  the  stomach  as  well  as  the  whole  body  is  at  rest.  Vomit- 
ing of  arterial  blood  is  present,  according  to  most  ol^scrvcrs,  in  from 
30  to  50  per  cent,  of  all  cases  of  gastric  ulcer;  and  minute  traces  of 
blood  can  usually  Ijc  found  in  the  vomitus  in  about  four-fifths  of  the 
cases.  Although  it  is  the  round  open  ulcer  that  is  ])articularly  char- 
acterized by  vomiting  of  arterial  blood,  yet  this  sym])t()m  may  Ije 


Symptomatology  of  Gastric  Ulcer.  79 

present  in  the  healing  ulcer.  In  the  latter  form,  however,  the  blood  is 
usually  much  less  in  quantity,  and  is  more  frequently  clotted  before 
it  is  vomited.  Hemorrhage,  as  well  as  vomiting,  are  later  signs  of 
gastric  ulcer  than  is  pain. 

Hemorrhage  into  the  stomach  in  cases  of  gastric  ulcer  does  not 
always  produce  immediate  vomiting.  The  blood  may  lie  in  the 
stomach  and  before  vomiting  occurs  may  become  clotted  or  intimately 
mixed  with  food  which  has  been  ingested  subsequent  to  the  occur- 
rence of  the  bleeding.  Or  the  blood  may  be  passed  into  the  intestines 
and  be  finally  evacuated  in  the  stools,  in  which  case  it  is  much  more 
liable  to  be  overlooked. 

A  consideration  of  hemorrhage  leads  naturally  to  a  discussion  of 
the  ancEmia  which  has  for  so  long  been  regarded  as  a  characteristic 
feature  of  the  open  gastric  ulcer.  It  is  still  an  undecided  question 
whether  the  typical  anaemia  is  a  cause  or  a  result  of  the  disease;  but 
it  is  at  any  rate  certain  that  it  is  a  fairly  constant  feature,  and  opinion 
at  present  is  inclined  to  consider  both  the  anaemia  and  the  gastric 
ulcer  as  produced  by  the  same  cause — toxaemia.  Particularly  in 
young  females  is  this  anaemia  noticed.  A  growing  girl  or  a  young 
woman  who  is  anaemic  and  has  indigestion  should  be  very  carefully 
examined  for  evidence  of  gastric  ulcer.  The  anaemia  is  usually  of  the 
chlorotic  type — that  is  to  say,  there  is  a  decrease  in  the  number  of  the 
red  blood  cells,  and  a  still  greater  decrease  in  the  amount  of  haemo- 
globin present;  the  cellular  elements  being  more  quickly  replaced 
after  hemorrhage  than  is  the  haemoglobin.  Inanition  due  to  the 
vomiting  and  to  the  impaired  digestive  powers  of  the  individual,  as 
well  as  the  recurring  hemorrhage  from  the  ulcer  itself,  are  important 
factors  in  maintaining  an  anaemia  which  has  once  developed. 

Besides  the  three  cardinal  symptoms  of  gastric  ulcer — pain,  vomit- 
ing, hemorrhage — and  the  anaemia  which  is  such  a  constant  feature 
of  the  disease,  there  are  other  signs  which  are  of  considerable  value 
in  making  a  diagnosis.  Hyperacidity  of  the  gastric  secretion  is  one 
of  the  most  important  of  these  additional  signs.  It  is  not  within  the 
purpose  of  this  volume  to  treat  of  the  technique  of  the  examination  of 
the  stomach  contents;  a  full  description  of  the  apparatus  required  to 


Benign  Diseases  of  the  Stomach  and  Duodenum. 


"C? 


obtain  them,  the  manner  in  which  it  is  employed,  the  test  meal  used 
by  us,  etc.,  will  be  found  at  p.  60. 

The  stomach  normally  empties  itself  in  from  four  to  six  hours 
after  an  ordinary  meal  has  been  eaten.  With  increased  gastric 
motility,  which  is  generally  present  in  open  gastric  ulcer,  the  time 
required  by  the  stomach  to  empty  itself  is  at  times  markedly  decreased. 
This  is  especially  true  if  the  meal  contains  a  large  proportion  of 
meat. 

As  a  rule  no  mass  can  be  detected  by  palpation  in  cases  of  open 
ulcer.  In  long-standing  ulcers,  attended  by  much  thickening  and 
many  adhesions,  the  presence  of  a  mass  is  not  so  rare. 

Hemorrhage  in  Ulcer  of  the  Stomach. 

As  a  general  statement  it  may  be  said  that  any  of  the  patho- 
logical varieties  of  ulcer  may  be  the  origin  of  any  form  of 
hemorrhage — of  a  sudden  and  fatal  flow  of  blood,  which 
kills  in  a  few  minutes;  of  repeated  hemorrhages  alarming  in 
quantity  but  not  immediately  lethal;  or  of  occult  hemorrhages  only 
to  be  detected  at  times  by  persistent  and  painstaking  microscop- 
ical examination  of  the  vomitus  and  the  faeces.  But  as  a  rule  those 
hemorrhages  which  occur  as  the  first  symptom  of  ulcer,  and  which 
quickly  kill  the  patient  by  their  mere  quantity,  are  found  to  have 
their  origin  in  erosions  of  the  mucous  membrane,  and  not  from  any 
well-defined  artery.  This  is  the  rule,  and  if  we  could  know  that  such 
a  form  of  ulceration  existed,  we  should  expect  any  hemorrhage  which 
might  occur  to  be  profuse  and  overwhelming  in  quantity  and  to  be 
quickly  fatal. 

Bleeding,  more  moderate  in  amount,  though  perhaps  still  alarming 
at  times,  but  which  ceases  before  the  patient  is  entirely  prostrated, 
and  again  recurs  in  similar  amounts  at  irregular  intervals  of  a  few 
weeks  or  months,  is  the  form  of  hemorrhage  which  is  sjjccially  charac- 
teristic of  the  round  open  ulcer.  In  such  cases  the  ulceration  in  its 
progress  opens  some  medium  sized  arterial  twig,  and  free  hemorrhage 
occurs  until  retraction  and  contraction  of  the  opened  vessel  allow  its 
mr)Uth  to  ]je  closed  Ijy  clotting.     A'enous  twigs  are  more  rarely  opened 


Hemorrhage  in  Gastric  Ulcer.  8i 

by  these  ulcers,  possibly  because  the  current  of  blood  in  them  is  slower, 
the  tension  less,  and  clotting  occurs  before  or  as  soon  as  the  vessel  is 
opened.  When  repeated  vomitings  are  merely  streaked  with  blood, 
the  hemorrhage  has  probably  arisen  in  some  such  way  as  this.  The 
callous  ulcer  has  as  its  characteristic  form  of  bleeding  the  "occult" 
hemorrhage  already  mentioned.  The  area  of  the  stomach  affected  is 
in  these  cases  anaemic,  being  very  largely  formed  of  scar  tissue,  and 
any  bleeding  that  occurs  usually  comes  from  some  abrasion  of  the 
stomach  wall  consequent  upon  the  stenosis  present,  or  else  arises  from 
some  portion  of  the  cicatrizing  area  which  has  not  yet  entirely  healed. 
But  if,  in  this  form  of  ulceration,  a  blood  vessel  of  any  size  is  per- 
forated, the  very  thickness  and  rigidity  of  the  margins  of  the  ulcer, 
which  were,  before,  the  patient's  protection  against  hemorrhage  and 
perforation,  become  now  his  destruction,  since  they  absolutely  pre- 
vent retraction  and  contraction  of  the  opened  vessel,  and  bleeding 
continues  until  the  patient  is  dead.  It  is  by  such  a  process  as  this  that 
the  splenic  or  hepatic  artery  or  one  of  their  branches  occasionally  is 
perforated,  the  chronic  ulcer  having  long  since  contracted  adhesions 
to  the  pancreas  or  its  surrounding  structures,  and  the  artery  being  fixed 
in  a  vise  of  cicatricial  connective  tissue. 

Hemorrhage  from  an  ulcer  of  the  stomach  is  not  always  manifested 
by  vomiting.  In  some  cases  of  profuse  hemorrhage  the  patient  sud- 
denly turns  pale,  becomes  giddy,  gasps  for  breath,  is  exceedingly 
thirsty;  his  pulse  becomes  feeble  and  rapid,  his  stomach  feels  full 
and  warm,  and  syncope  may  be  followed  by  death  without  further 
warning.  If  the  bleeding  be  less  profuse,  and  still  no  vomiting  occur, 
life  may  be  prolonged  for  a  couple  of  days,  the  patient  presenting, 
after  the  symptoms  of  internal  hemorrhage,  those  of  mild  sepsis,  with 
fever  and  delirium.  Black  spots  may  float  before  the  eyes,  or  the 
amblyopia  may  be  complete. 

The  more  profuse  the  hemorrhage,  the  more  apt  it  is  to  be 
due  to  ulcer,  and  not  to  carcinoma  or  to  portal  congestion  or 
gastritis.  In  these  latter  conditions  the  amount  of  blood  lost 
is  rarely  more  than  a  few  ounces,  and  usually  clots  before  being 
vomited;  but  a  pint  or  more  is  not  unfrequently  lost  in  cases  of  ulcer. 
After  a  hemorrhage  of  even  less  amount,  the  patient  may  present  the 
6  " 


82         Benign  Diseases  of  the  Stomach  and  Duodenum. 

signs  of  secondary  ana?mia  for  some  weeks.  Dyspnoea  may  occur  on 
the  least  exertion;  the  extremities  may  remain  cold  and  clammy; 
tinnitus  aurium  may  be  an  annoying  feature;  restlessness  or  even 
delirium  may  disturb  the  sleep.  Irregular  fever  may  persist  in  some 
patients  for  many  weeks.  This  symptom,  although  always  arousing 
suspicions  of  perigastric  abscess,  may  be  due  to  mild  sepsis  from  a 
sloughing  ulcer,  which  even  a  successful  gastro-enterostomy  cannot 
relieve  at  once,  or  may  possibly  be  merely  an  evidence  of  the  severe 
secondarv  anaemia. 


Perforation  of  Gastric  Ulcers. 

This  serious  complication,  which  is  said  to  occur  in  about 
four  per  cent,  of  all  cases,  and  to  constitute  eighty  per  cent, 
of  the  deaths  due  to  the  disease,  arises  from  various  and 
rather  ill-defined  causes.  As  in  the  case  of  hemorrhage,  so  also 
a  perforation  may  be  inaugurated  either  by  physical  means,  or 
by  the  pathological  processes  of  ulceration  or  sloughing.  When  an 
acute  ulcer  is  subjected  to  sudden  strain,  as  in  vomiting,  or  is  abraded 
by  ingested  food,  its  base  may  give  way,  and  the  peritoneal  cavity  be 
opened.  Chronic  ulcers  arc  not  so  apt  to  be  affected  in  this  manner, 
partly  because  of  the  thickness  of  their  bases  and  margins,  but  more 
especially  because  perigastritis  usually  has  existed  for  some  time,  and 
as  a  consequence  the  general  peritoneal  cavity  is  protected  by  adhe- 
sions. Adhesions  are  said  to  form  in  about  two-fifths  of  the  cases  of 
perforation.  When,  in  an  acute  ulcer,  the  perforation  arises  from 
the  physical  causes  just  mentioned,  the  solution  of  continuity  is  fre- 
quently slit-like  in  character;  but  when  due  to  the  extension  of  the 
ulcerating  process,  or  to  sloughing,  the  perforation  is  more  or  less 
circular.  It  is  gencralh'  found  lliat  the  larger  perforations  are  due  to 
the  separation  of  a  sk)ugh,  and  that  those  produced  by  progressing 
ulceration  are  minute  in  size,  and  give  rise  to  symptoms  less  acute  than 
the  other  varieties  of  ])erf()ralion. 

Perforations  vary  by  actual  measurement  from  those  which  can  Ije 
classed  merely  as  pin-point  to  those  which  will  aflmit  two  or  three 
fingers  and  measure  two  or   three  inches  in  (lianuter.     The  average 


Perforation  of  Gastric  Ulcers. 


83 


perforation,  however,  does  not  exceed  a  quarter  or  a  half  an  inch 
in  diameter. 

As  a  rule  there  is  not  more  than  one  perforation  present;  but  in 
about  twenty  per  cent,  of  cases  two  or  more  have  been  found;  hence 
it  is  always  well  to  search  the  gastric  surface  thoroughly,  and  in  cases 
of  doubt  to  establish  free  drainage  of  suspicious  regions. 

Since  it  makes  a  very  considerable  difference  not  only  in  the 
initial  symptoms  but  also  in  the  facility  of  subsequent  treatment, 
whether  the  perforation  be  on  the  anterior  wall  of  the  stomach,  and 
easily  accessible,  or  near  the  fundus,  or  on  the  posterior  wall,  it  is  very 
important  for  the  surgeon  to  be  familiar  with  the  usual  sites  of  per- 
foration, and  with  the  clinical  course  pursued  by  the  ulcer  in  each  case. 

The  statistics  collected  by  various  investigators  show  that  although 
gastric  ulcer  occurs  most  frequently  on  the  posterior  wall  of  the  stom- 
ach, yet  that  perforations  occur  with  greatest  frequency  on  the  anterior 
wall.  This  difference  is  well  seen  in  the  tables  published  a  few  years 
since  by  A.  P.  C.  Ashhurst. 

TABLE  I.— SHOWING  SITE  OF  GASTRIC  ULCER  IN  GENERAL. 


Author. 

Ante-    Lesser 
RiOR      Curva- 
Wall.  !   ture. 

Poste- 
rior 
Wall. 

Pylo- 
rus. 

Fun- 
dus. 

Anterior 
Car-      and  Pos- 
dia.         terior 
Walls. 

Greater 
Curva- 
ture. 

Total. 

Brinton 

Welch 

10      1       56 
69      J     288 

86 

235 

32 
95- 

0             4             13 

29       i    50       i        0 

5 
27 

206 
7Q3 

Per  cent 

8     i    34-4 

32.1 

12.7 

2.9 

5-4 

1-3 

3-2 

fl » 9 
1  ou 

TABLE  II.— SHOWING  SITE  OF  PERFORATED  GASTRIC  ULCERS. 


Author. 

Ante- 
rior 
Wall. 

Lesser 
Curva- 
ture. 

Poste- 
rior 
Wall. 

Pylo- 
rus. 

Fun- 
dus. 

Car- 

DIA. 

Anterior 
AND  Pos- 
terior 
Walls. 

Greater 
Curva- 
ture. 

Total. 

Bidwell 

Comte 

36 
28 

3 
4 

8 
8 

0 
3 

0 
0 

0 
0 

I 
0 

0 
0 

47 

43 

Per  cent 

71. II 

6.67 

17.78 

3-33 

0 

° 

I. II 

0 

100 

As  Ashhurst  remarks,   "although   the   numbers   in   the   second 
table  are  less  than  one-tenth  of  those  involved  in  the  first,  yet  the 


84         Benign  Diseases  of  the  Stomach  and  Duodenum. 


Fig.  16. — DiAGEAM  Showing  Sites  of 
Perforated  Gastric  Ulcers. 

A,  cardia;  B,  fundus;  C,  body  of  stomach; 
D,  pyloric  portion;  E,  pylorus.  Per- 
forations on  the  posterior  wall  are 
infiicated  by  lighter  shading. 


difference  in  the  result  is  so  great  that  the  relation  could  scarcely  be 
materially  disturbed,  even  were  the  number  of  perforations  recorded 

to  equal  that  of  the  total  num- 
ber of  ulcers  observed."  The 
reason  for  this  difference  lies 
not  in  any  difference  in  the 
ulcers  themselves,  but  in  the 
relations  of  the  stomach  to  sur- 
rounding viscera.  The  anterior 
wall  of  the  stomach  is  exposed 
to  the  general  peritoneal  cavity, 
is  subject  to  a  greater  degree  of 
dilatation  and  contraction  than 
is  the  posterior,  and  is  also 
more  exposed  to  external  trauma 
acting  through  the  abdominal 
walls.  The  posterior  is  placed 
in  contact  with  the  relatively 
rigid  and  immovable  spinal  column,  within  the  limited  confines  of 
the  lesser  peritoneal  cavity,  and  in  close  relation  with  the  pancreas,, 
duodenum,  and  Spigelian  lobe 
of  the  liver.  Being  thus  pro- 
tected, ulcers  on  the  posterior 
gastric  surface  are  prone  to  in- 
duce perigastric  adhesions  as 
soon  as  any  peritoneal  irritation 
is  developed,  and  being  so  rein- 
forced are  neither  so  apt  to  per- 
forate, nor  to  ])roducc  diffuse 
jjcritonitis  in  ihc  rare  event 
of  their  actual  perforation,  as 
are  those  placed  in  less  well- 
protected  situations.  The  loca- 
tion of  gastric    jjcrforations  is  well  sliown  in  Figs.  i()  and  17. 

Perforation  of  gastric  ulcers  has  been  well  described  as  acutCy 
subacute,  or  chronic  in  character.     These  terms  refer  not  so  much  to 


I-'ig.  17. — Diagram    Showing    Sites    of 
Perforated  Gastric  Ulcers. 


Perforation  of  Gastric  Ulcers.  85 

the  symptoms  produced,  as  to  the  pathological  course  of  the  peritonitis 
caused  by  the  perforation.  An  ulcer  which  perforates  acutely  is  one 
such  as  those  on  the  anterior  wall  which  bursts  through  into  the 
peritoneal  cavity  by  sloughing  or  from  the  effect  of  physical  forces, 
without  having  previously  set  up  by  contiguity  a  limited  plastic  peri- 
tonitis sufficient  to  protect,  for  a  time  at  least,  the  general  peritoneum 
from  invasion.  An  ulcer  which  perforates  subacutely  is  one  whose 
base  is  gradually  ulcerated  through,  so  that  perigastritis  with  its 
premonitory  symptoms  precedes  the  actual  solution  of  continuity; 
and  so  that  when  this  solution  of  continuity  occurs,  there  is  either  a 
spreading  plastic  peritonitis  already  inaugurated,  or  adhesions  are 
present  which  are  more  or  less  capable  of  limiting  the  outflow  of  the 
gastric  contents.  By  the  term  chronic  perforation  is  indicated  that 
process  which  ensues  when  the  base  of  an  ulcer  is  adherent  to  some 
neighbouring  organ,  so  that  practically  no  additional  symptoms  are 
produced  at  the  actual  moment  when  the  gastric  wall  ceases  to  form 
the  floor  of  the  ulcer,  and  its  place  is  taken  by  pancreatic  or  hepatic 
tissue,  or  by  firm  fibrino-plastic  material — so  that,  in  short,  the  symp- 
toms which  first  call  attention  to  the  changed  condition  are  not  those 
of  perforation  nor  peritonitis,  but  of  sepsis,  induced  by  slow  absorption 
from  some  variety  of  perigastric  or  subphrenic  abscess. 

Subphrenic  abscess  (p.  443)  has  as  its  most  frequent  cause  gastric 
ulcer.  Indeed,  the  more  we  learn  of  the  upper  abdomen,  the  rarer 
seem  to  become  the  cases  of  subphrenic  abscess  found  in  connection 
with  any  other  disease,  such  as  cholecystitis,  appendicitis,  or  suppura- 
tive hepatitis.  The  term  subphrenic  abscess,  so  indiscriminately  used, 
is  in  many  instances  a  misnomer,  since  the  purulent  collection  is 
frequently  subhepatic  or  retrocolic  in  location,  and  bears  no  direct 
relation  to  the  diaphragm.  When  arising  from  a  perforation  on  the 
anterior  wall  of  the  stomach,  the  abscess  is  usually  found  beneath  the 
left  lobe  of  the  liver;  and  if  it  extend  forward  may  come  finally  into 
direct  contact  with  the  parietal  peritoneum  of  the  anterior  abdominal 
wall.  Perigastric  abscess  as  a  result  of  an  ulcer  on  the  anterior  wall  of 
the  stomach  is  a  rather  unusual  occurrence,  and  when  found,  the  ulcer 
is  nearly  invariably  placed  close  to  the  lesser  curvature  of  the  stomach. 
Under  these  circumstances  the  stomach  wall  forms  the  lower  wall  of 


86         Benign  Diseases  of  the  Stomach  and  Duodenum. 

the  abscess  cavity,  the  gastro-hepatic  omentum  its  posterior  boundary, 
while  its  roof  is  formed  by  the  left  lobe  of  the  liver,  and  its  anterior 
wall  by  adhesions,  or  possibly  by  the  omentum.  If  the  perforation 
occur  toward  the  fundus  of  the  stomach,  the  spleen  may  form  one  of 
the  boundaries  of  any  abscess  that  forms;  while  if  near  the  cardiac 
opening  a  true  subdiaphragmatic  abscess  may  result.  In  rare  cases  a 
perigastric  abscess  on  the  anterior  wall  has  been  known  to  perforate 
the  colon,  forming  a  gastro-colic  fistula.  The  duodenum  and  the  gall- 
bladder may  also  be  perforated. 

On  the  posterior  surface  of  the  stomach  perigastric  abscess  may 
occupy  any  of  several  not  very  unusual  positions.  Even  when  the 
ulcer  is  situated  near  the  lesser  curvature  it  has  been  found  to  form 
adhesions  to  the  Hver  only  one-third  as  often  as  it  does  to  the  pancreas. 
Occasionally  the  whole  of  the  lesser  peritoneal  cavity  becomes  in- 
volved, forming  an  empyema  of  the  bursa  omentalis.  The  general 
rule  for  the  extension  of  these  abscesses  is  that  they  tend  to  enlarge 
most  in  the  direction  of  that  portion  of  their  walls  which  is  formed  by 
adhesions.  If  the  abscess  is  in  relation  with  the  pancreas  or  the 
duodenum,  it  is  not  apt  to  extend  into  the  substance  of  the  one  nor  to 
perforate  the  lumen  of  the  other  even  if  their  surface  be  penetrated; 
though  either  event  may  occur  in  rare  instances.  But  when  the  liver 
forms  one  of  the  boundaries  of  a  perigastric  abscess,  its  soft  and  friable 
texture,  in  marked  contrast  to  the  hbrous  structure  of  the  pancreas, 
oilers  very  slight  resistance  to  the  purulent  invasion  when  once  the 
capsule  of  Glisson  has  been  penetrated.  If  the  abscess  extend 
posteriorly  without  invading  the  liver  substance,  it  will  work  its  way 
up  between  the  Spigelian  lobe  and  the  crus  of  the  dia])lira,u;m,  and 
become  in  reality  a  subjjhrenic  abscess.  In  this  situation  the  sinuous 
course  taken  by  the  y)us  in  the  effort  to  evacuate  itself  is  sometimes 
truly  remarkable.  The  ])eri(ar(lium  ma}'  be  entered  after  ])erforation 
of  the  diaphragm,  causing  sudden  death,  as  in  the  case  narrated  by 
P'enwick;  the  pleura  may  be  invaded,  ])roducing  pyopneumothorax,  as 
in  cases  recorded  by  Bid  well,  Mackenzie,  and  others;  or  the  anterior 
or  lateral  al;flominal  walls  may  be  readied  b)-  such  (le\i()us  and  cir- 
cuitous routes  as  almost  to  elude  detection. 

Symptoms. — The  initial  symptoms  of  perforation  of  any  portion 


Perforation  of  Gastric  Ulcers.  87 

of  the  digestive  tract  bear  a  family  resemblance  to  each  other,  and  it  is 
mainly  by  attention  to  the  previous  history  of  the  case,  and  to  certain 
rather  ill-defined  differential  points,  that  a  decision  can  be  reached  as 
to  the  particular  part  affected. 

Sudden,  severe,  burning  pain  is  nearly  invariably  the  first  symptom. 
It  is  usually  localized  in  the  epigastric  or  umbilical  region,  showing  no 
tendency  to  shoot  from  one  portion  of  the  belly  to  another,  nor  to  be 
referred  to  the  hypochondriac  or  scapular  regions.  The  pain  is  fre- 
quently so  severe  as  to  compel  the  patient  to  cry  out;  it  affects  him 
like  a  cramp:  he  doubles  up  his  thighs  toward  his  abdomen,  and 
bows  his  body  to  his  thighs,  pressing  his  hands  into  his  belly.  Any  one 
who  has  watched  even  one  of  these  patients  will  never  forget  the  sight. 
This  agonizing  pain  may  persist  for  fifteen  or  thirty  minutes ;  ordi- 
narily it  is  quickly  succeeded  by  symptoms  of  collapse.  The  collapse, 
recognized  by  the  anxious  cast  of  countenance,  the  cold  and  clammy 
surface,  the  sudden  pallor,  the  guarded  breathing,  and  the  quickening, 
feeble  pulse,  is  probably  due  to  the  escape  of  air  from  the  intestinal 
tract  into  the  peritoneal  cavity.  That  it  is  not  due  merely  to  the 
presence  of  air  within  the  peritoneal  cavity  is  abundantly  proved  by 
the  absence  of  such  symptoms  when  the  peritoneum  is  widely  exposed 
to  the  air  during  operations  even  without  general  anaesthesia.  (See 
p.  124.)  The  change  in  blood  pressure  produced  by  the  sudden 
transference  of  air  from  within  the  intestine  or  stomach  to  the  peri- 
toneal cavity  surrounding  them,  seems  to  produce  an  immediate 
constitutional  effect  through  the  sympathetic  nerves;  and  this  effect 
is  what  we  call  shock.  This,  then,  is  the  state  which  ensues  very 
soon  after  the  initial  pain  has  made  its  appearance.  When  shock  is 
fully  developed,  the  senses  are  so  obtunded  that  pain  is  no  longer 
recognized  as  such,  or  at  the  very  least  its  character  changes,  and  it 
becomes  less  unendurable. 

After  the  first  onset  of  pain,  the  patient  often — in  from  fifty  to 
sixty  per  cent,  of  cases — vomits,  but  this  act  is  not  commonly  repeated, 
thus  giving  us  one  important  point  of  distinction  between  perforation 
and  obstruction  or  strangulation  of  the  bowel.  Vomiting  is  a  serious 
feature,  since  it  forces  the  stomach  contents  out  not  only  by  way  of 
the  oesophagus,  but  also  through  the  perforation  into  the  peritoneal 


88  Benign  Diseases  of  the  Stomach  and  Duodenum. 

cavity.  If  the  stoniach  be  empty  at  the  time  perforation  occurs,  the 
nausea  will  produce  retching  only,  and  at  most  a  little  fluid,  occa- 
sionally blood  stained,  will  be  vomited. 

Not  until  peritoneal  reaction  has  commenced  does  marked  rigidity 
of  the  abdominal  wall  appear.  If  the  infection  be  overwhelming,  it  may 
never  appear,  but  the  patient  will  sink  under  the  lethal  influence  of  the 
toxic  peritonitis,  without  an  effort  at  repair  of  the  lesion  by  plastic 
exudation.  Tenderness  arises  at  the  same  time  as  rigidity.  The 
patient  will  no  longer  feel  the  pain  as  a  cramp-like  affection;  he  will 
draw  up  his  thighs  so  as  to  relax  the  abdominal  muscles,  and  will 
protect  his  belly  from  the  slightest  pressure.  The  tenderness  thus 
developed  may  persist  after  extensive  peritoneal  involvement  with  its 
consequent  tympany  has  rendered  rigidity  inappreciable.  Of  the 
two  symptoms,  however,  rigidity  is  the  more  positive. 

Thirst  is  a  very  frequent  symptom  of  gastro-intestinal  perforations. 
Although  nausea  be  present,  and  even  if  the  initial  vomiting  be  re- 
peated, the  patient  will  be  very  apt  to  drink  water  time  and  again,  in 
the  vain  effort  to  relieve  his  thirst.  During  the  height  of  the  attack  the 
urine  is  scanty  or  altogether  suppressed. 

The  escape  of  air  into  the  peritoneal  cavity  may  in  some  instances 
be  so  great  as  to  cause  a  diminution  or  an  actual  obliteration  of  the 
liver  dullness.  This  is,  however,  a  sign  on  which  absolute  reliance 
cannot  be  placed.  Extreme  tympany  without  any  perforation  may 
produce  similar  physical  signs,  and  even  when  a  large  amount  of  air 
is  free  within  the  peritoneal  cavity  the  liver  dullness  may  persist. 

If  free  air  be  present  in  the  ])eritoneal  cavity  under  even  slight 
pressure,  it  may  be  detected  by  means  of  the  coin  test  so  frequently 
used  in  the  diagnosis  of  pneumothorax.  If  one  coin  be  placed  on  the 
abdominal  wall  and  struck  by  another  coin,  the  presence  of  air  within 
the  abdominal  ('a\ity  will  be  revealed  by  a  clear  metallic  sound, 
distinctly  heard  through  a  stethoscope  or  by  the  ear  held  on  the  ab- 
dominal wall  near  the  coin.  If  the  area  of  metallic  sound  be  not 
circumscribed,  as  it  would  be  if  the  air  were  within  the  stomach  or  a 
portion  of  the  intestinal  tract,  free  air  within  Ihr  jjcritoneal  cavity  can 
be  diagnosticated,  and  this  sign  is  claimed  by  man)'  to  be  ])athogno- 
monic  of  perforation  of  the  gastro-intestinal  tract. 


Perforation  of  Gastric  Ulcers.  89 

Emphysema  of  the  subcutaneous  tissues,  a  very  unusual  symptom, 
was  first  noted  in  a  case  of  gastric  perforation  by  Demarquay  (1866). 

Immediately  after  perforation  of  any  portion  of  the  gastro-intes- 
tinal  tract,  the  temperature  is  apt  to  fall.  We  attach  considerable 
importance  to  this  symptom,  and  believe  that  if  the  temperature  were 
taken  without  fail  immediately  after  the  initial  pain  appeared,  it 
would  be  found  subnormal  with  greater  regularity  than  the  state- 
ments of  some  writers  would  lead  one  to  believe. 

Accompanying  or  closely  following  the  fall  of  temperature,  there 
is  a  quickening  of  the  pulse;  and  if  operation  be  not  undertaken 
promptly,  the  local  tenderness  and  rigidity  will  spread  over  the  ab- 
domen. 

Diagnosis.- — Acute,  overwhelming  pain,  vomiting,  fall  of  temper- 
ature, rise  of  pulse,  shock,  and  peritoneal  reaction — these  are  the 
symptoms  of  perforation  into  the  peritoneal  cavity  in  general;  and, 
as  was  remarked  in  the  beginning,  it  remains  to  determine  in  the 
presence  of  these,  what  portion  of  the  gastro-intestinal  tube  is  affected. 

In  anaemic  young  women  the  surgeon's  thoughts  would  naturally 
turn  to  gastric  ulcer  as  the  cause  of  the  perforation,  and  ninety-nine 
times  out  of  one  hundred  he  would  be  correct,  even  in  the  absence  of  a 
history  of  gastric  disease.  Such  history  usually  can  be  elicited  in 
over  ninety  per  cent,  of  patients  with  gastric  perforations.  English 
found  it  present  in  forty  out  of  fifty  cases  of  gastric  and  duodenal 
perforation,  no  previous  history  of  any  kind  being  obtainable  in  five 
of  the  cases,  and  a  previous  history  of  gastric  disease  being  absent  in 
only  five  of  the  patients. 

In  an  adult  man,  duodenal  ulcers  are  more  apt  to  be  the  cause  of 
perforation  than  are  gastric,  and  where  no  history  is  obtainable,  that 
portion  of  the  digestive  tract  should  be  explored  first  in  such  patients. 
Of  course  if  there  were  a  clear  history  of  preceding  gastric  symptoms, 
it  would  be  difiicult  for  no  one  to  make  the  diagnosis  of  gastric  or 
duodenal  perforation ;  but  in  the  absence  of  such  history  there  are 
no  pathognomonic  symptoms  by  which  we  can  certainly  distinguish 
between  these  two,  or  even  between  perforation  occurring  in  the  upper 
and  that  occurring  in  the  lower  portions  of  the  abdomen.  Those 
portions  of  the  gastro-intestinal  tract  which  most  frequently  perforate 


90  Benign  Diseases  of  the  Stomach  and  Duodenum. 

are  the  appendix,  the  ileum,  the  stomach,  and  the  duodenum;  and 
the  frequency  of  perforation  is  probably  in  the  order  named.  But 
the  appendix  rarely  perforates  without  some  premonitory  attacks, 
and  even  when  it  does  perforate  into  the  general  peritoneal  cavity, 
the  symptoms  produced  are  not  of  so  alarming  and  prostrating  a 
nature  as  when  some  portion  of  the  digestive  tube  with  a  larger  calibre 
is  perforated.  Perforations  of  the  ileum  are  rare,  except  during  ty- 
phoid fever;  and  the  occurrence  of  symptoms  of  peritoneal  perfora- 
tion during  typhoid  fever  would  naturally  suggest  the  ileum  as  the 
part  affected.  Typhoid  ulcers  of  the  stomach  are  extremely  rare. 
(See  page  70.) 

In  diagnosticating  perforations  of  the  upper  abdomen,  when  the 
clinical  history  is  negative,  we  must  rely  chiefly  upon  the  location  of 
the  initial  pain,  and  upon  the  directions  in  which  peritoneal  involve- 
ment proceeds.  Although  perforations  in  other  portions  of  the  ab- 
domen sometimes  produce  epigastric  pain,  it  is  rare  for  gastric  per- 
forations to  cause  other  than  epigastric  pain.  Then,  too,  in  gastric 
and  duodenal  perforations,  the  general  peritoneal  cavity  is  more 
quickly  involved  than  in  perforative  lesions  of  the  lowTr  abdomen. 
In  the  latter  it  is  the  pelvis  that  is  usually  first  involved  by  extension, 
and  the  umbilical  and  epigastric  regions  do  not  become  affected  until 
later;  whereas  Avhen  the  perforation  is  in  the  stomach  or  duodenum, 
these  regions  are  immediately  affected,  and  it  is  only  by  gravitation  of 
liquids  that  the  lower  portions  of  the  abdomen  are  involved.  In  the 
majority  of  gastric  perforations  the  transverse  colon  and  the  great 
omentum  protect  the  h}npogastric  region  and  the  pelvis  from  invasion, 
and  as  the  splenic  flexure  of  the  colon  is  almost  invariably  higher  than 
the  hepatic,  any  fluid  extravasatcd  above  it  tends  to  flow  toward  the 
right.  These  facts,  as  well  as  the  anatomical  relations  of  the  ascend- 
ing mesocolon,  tend  to  make  fluids  from  jjcrforalions  in  the  u])])cr  ab- 
domen collect  first  in  the  right  kidney  pouch,  and  then  in  the  right 
iliac  fossa.  When  a  patient  presents  such  symptoms  as  these  when 
seen  for  the  first  time,  the  resemblance  to  a])pendicular  abscess  is 
very  close,  and  the  diagnosis  of  gastric  jjcrforalion  is  ])ra(lically  never 
made  before  operation,  especially  where  no  history  of  jjrevious  gastric 
disease  can  be  elicited.     Such  cases  have  Ijccn  recorded  l:)yKammercr, 


Perforation  of  Gastric  Ulcers.  91 

and  by  Harte  who  mentions  the  speed  with  whicli  fermentative  changes 
occur  in  the  upper  intestinal  tract,  and  notes  the  consequent  presence 
of  gas  in  the  peritoneal  cavity  (when  the  abdomen  is  opened)  as  a 
sign  suggestive  of  the  high  location  of  the  perforation. 

In  some  instances,  when  the  existence  of  a  gastric  ulcer  is  known, 
the  onset  of  a  subacute  perforation  may  be  recognized  by  premonitory 
symptoms  for  several  days  beforehand.  Fleeting  pain  of  a  stab-like 
character,  or  merely  vague  feelings  of  increased  gastric  distress  may 
be  present;  and  cases  are  known  where  deep  breathing  or  sudden 
turning  of  the  body  have  caused  exacerbations  of  the  pain  by  a  sudden 
pull  on  newly  formed  adhesions.  Robson  and  Moynihan  mention  a 
patient  who  said  that  it  hurt  her  to  bend,  as  her  side  felt  stiff.  In 
cases  such  as  these  the  moment  of  actual  perforation  is  not  attended 
by  such  violent  pain  nor  by  such  marked  collapse  as  when  the  per- 
foration is  acute;  and  a  temporary  lull  may  occur,  during  which  the 
symptoms  abate,  and  a  perigastric  abscess  forms.  Unless  promptly 
relieved  by  operation  such  patients  will  perish  from  sepsis  or  from 
subsequent  generalized  peritonitis. 

The  symptoms  of  chronic  perforations  of  the  stomach  are  those  of 
perigastric  and  subphrenic  abscess.  Strict  attention  to  the  clinical 
history  of  the  patient,  with  a  painstaking  and  if  need  be  oft-repeated 
physical  examination  w^ill  enable  the  diagnosis  to  be  made  in  the 
majority  of  cases.  Evidences  of  sepsis,  with  progressive  emaciation, 
hectic  fever,  chills  and  sweats,  and,  above  all,  persistent  tenderness  to 
pressure,  will  be  the  surgeon's  best  guide.  Further  consideration  will 
be  given  this  subject  in  a  subsequent  chapter.     (See  p.  442.) 

Differential  Diagnosis. — Although,  with  a  clear  history  and  char- 
acteristic symptoms,  such  as  those  already  detailed,  the  diagnosis  of 
gastric  perforation  may  be  considered  an  easy  problem,  yet  in  not  a 
few  instances  mistakes  have  been  made  by  capable  surgeons.  Even 
with  symptoms  so  typical  as  to  leave  no  reasonable  room  for  doubt, 
abdomens  have  been  opened,  and  yet  no  lesion  whatever  has  been 
found,  and  the  patients  have  gone  on  to  satisfactory  recovery.  And  in 
a  somewhat  less  limited  number  of  cases  some  lesion  other  than  gastric 
perforation  has  been  discovered  either  at  operation  or  autopsy.     The 


92         Benign  Diseases  of  the  Stomach  and  Duodenum. 

importance  of  attentively  considering  the  differential  diagnosis  of  this 
comphcation  is  therefore  very  evident. 

Perjoration  0}  duodenal  ulcer  is  the  condition  which  in  every 
respect  most  closely  resembles  the  perforation  of  a  gastric  ulcer. 
Indeed,  so  close  is  the  resemblance  that  differentiation  from  symptoms 
alone  is  usually  impossible,  and  the  surgeon  must  rely  on  the  age,  sex, 
and  previous  history  of  the  patient  in  drawing  his  conclusions.  Since 
immediate  operation  is  indicated  in  either  case,  and  as  the  technique 
in  both  cases  is  practically  the  same,  the  distinction  is  in  this  instance 
of  more  academic  than  practical  importance. 

Though  rare,  it  is  not  an  unheard  of  thing  for  peritonitis  to  arise 
in  gastric  disease  without  any  actual  perforation.  McCosh  has 
recorded  the  case  of  a  patient  in  whom  strangulation  of  a  gastric 
pol^-p  produced  gangrenous  gastritis,  with  the  formation  of  an  abscess 
which  gravitated  to  the  right  iliac  fossa,  and  later  caused  death  from 
general  peritonitis.  Harte  has  observed  a  case  in  which  a  septic 
gastritis,  arising  during  an  attack  of  acute  nephritis,  with  unemia, 
caused  all  the  symptoms  of  a  gastric  or  duodenal  perforation,  and  in 
which  death  ensued  from  generalized  peritonitis,  no  macroscopic 
perforation  being  discoverable  at  autopsy. 

Acute  appendicitis  differs  in  several  respects  in  the  symptoms  it 
usually  presents,  and  as  a  rule  need  not  be  confused  with  a  gastric 
perforation,  especially  if  the  latter  be  of  the  acute  variety.  Many 
cases  of  subacute  perforation  of  the  stomach  resemble  suppurative 
appendicitis  very  closely,  and  are  frequently  not  to  be  distinguished 
until  after  the  abdomen  has  been  opened.  In  acute  appendicitis  the 
initial  pain  is  diffuse,  colicky,  and  wave-like  in  character;  at  a  later 
period  it  settles  into  the  right  iliac  fossa.  There  is  little  if  any  collapse ; 
fall  of  temperature  is  rare;  abdominal  rigidity  is  well  localized  to  the 
region  of  the  appendix,  and  general  peritoneal  invasion  is  often  delayed 
for  one  or  two  days,  a  palpable  mass  meantime  forming  in  the  right 
iliac  fossa.  The  pain  in  acute  gastric  perforation  is  overwhelming, 
and  though  local  at  first,  very  quickly  becomes  general;  the  shock  is 
profound,  the  temjjerature  falls,  and  the  ])atient  appears  in  imminent 
danger  of  death;  as  reaction  commences,  e\'idencesof  general  ])eritonitis 
are  found,  and  at  a  much  earlier  i)eriod  than  is  the  case  in  appendicitis. 


Perforation  of  Gastric  Ulcers.  93 

Ruptured  extrauterine  pregnancy  resembles  gastric  perforation  in 
the  agonizing  pain,  the  profound  collapse,  and  the  usual  sex  of  the 
patient.  But  the  previous  histories  are  different;  the  location  of  the 
pain  is  not  the  same;  evidences  of  internal  hemorrhage  frequently 
persist,  and  overshadow  the  rather  tardy  developement  of  peritonitis ; 
and  a  vaginal  examination  may  detect  an  exquisitely  tender  tumor 
in  the  pelvis. 

Acute  intestinal  obstruction  is  not  characterized  by  symptoms  of 
peritonitis  until  strangulation  occurs.  Vomiting  is  persistent,  becoming 
stercoraceous  in  time ;  rigidity  is  not  pronounced ,  and  relief  from  the  pain 
may  even  be  obtained  by  pressure  and  massage  of  the  abdomen  at  a 
time  long  after  diffuse  peritonitis  would  have  arisen  were  the  case  one 
of  gastric  perforation.  Obstipation  is  absolute;  collapse  is  wanting 
unless  perforation  occurs  above  the  strangulated  area,  and  the  temper- 
ature remains  normal  or  subnormal  until  the  advent  of  peritonitis. 
The  previous  history  of  the  patient  may  reveal  the  cause  of  the  ob- 
struction in  long-standing  peritoneal  adhesions,  or  physical  examina- 
tion may  detect  a  strangulated  hernia  or  an  ill-defined  abdominal 
tumor — possibly  a  volvulus,  an  intussusception,  or  a  pelvic  tumor 
with  twisted  pedicle. 

Gall-stone  colic  and  acute  cholecystitis  are  usually  sufficiently 
distinguished  by  their  clinical  history,  the  location  of  their  physical 
signs,  and  the  absence  of  shock,  with  the  slower  developement  of 
peritonitis. 

Acute  hemorrhagic  pancreatitis  resembles  gastric  perforation  in  the 
intensity  of  the  pain  and  the  profundity  of  the  shock.  No  history  of 
gastric  ulcer  is  as  a  rule  obtainable,  however,  nor  does  the  affection 
occur  in  anaemic  young  females.  The  typical  subjects  of  pancreatitis 
are  obese,  alcoholic  individuals  of  middle  life.  There  may  be  pal- 
pable, in  the  region  of  the  pancreas,  a  deep  seated  tumor,  which  does 
not  move  with  respiration,  and  which  may  reveal  an  indistinct  sense 
of  fluctuation.  These  features  somewhat  resemble  those  which  arise 
in  cases  of  perigastric  abscess  or  empyema  of  the  bursa  omentalis,  due 
to  subacute  or  chronic  perforations  of  gastric  ulcers ;  and  though  some 
assistance  in  making  the  diagnosis  may  be  obtainable  by  the  possible 
occurrence,  in  pancreatitis,  of  jaundice,  fatty  diarrhoea,  and  glycosuria, 


94         Benign  Diseases  of  the  Stomach  and  Duodenum. 

yet  in  many  cases  differentiation  before  opening  the  abdomen  is 
impossible. 

Mesenteric  tliromhosis  is  anotlier  affection  which  is  sometimes  con- 
fused with  perforation  of  gastric  ulcers.  It  is,  however,  a  compara- 
tively rare  occurrence;  and  is  not  characterized  by  abrupt  onset, 
shock,  nor  early  peritonitis.  Indeed,  when  the  thrombosis  is  arterial, 
there  are  no  well-recognized  symptoms  by  which  a  diagnosis  can  be 
made,  the  affected  bowel  becoming  the  seat  of  dry  gangrene.  If 
venous  obstruction  arises,  the  symptoms  are  more  acute;  there  are 
vague  abdominal  pains,  continuous  but  paroxysmal;  a  little  fever, 
possibly  vomiting;  sometimes  bloody  stools;  and  finally  the  evidence 
of  peritonitis.  But  the  course  is  much  less  acute  than  in  gastric 
perforations,  and  all  the  symptoms  less  severe. 

Ptomaine  poisoning  is  characterized  by  a  similar  onset — acute 
abdominal  pain,  nausea,  vomiting,  and  collapse.  The  collapse  may 
be  great,  the  temperature  subnormal,  and  the  skin  cold  and  clammy. 
Diarrhoea,  however,  is  often  a  salient  feature,  and  the  vomiting  is  more 
persistent  than  in  cases  of  gastric  perforation.  Although  the  ph5'^sical 
signs — tenderness,  rigidity,  and  distention — are  the  same  in  both 
affections,  distention  occurs  much  earlier  in  ptomaine  poisoning  than 
when  due  to  peritonitis  from  gastric  perforation.  In  ptomaine 
poisoning,  also,  a  history  of  the  ingestion  of  suspected  food  stuffs  can 
usually  be  obtained;  and  a  period  of  incubation  (varying  from  twelve 
to  thirty-six  or  forty-eight  hours)  between  the  ingestion  of  the  poison 
and  the  developement  of  symptoms  will  usually  be  found  to  have 
elapsed.  During  this  period  of  incubation  the  patient  may  have  been 
seemingly  well,  or  there  may  have  been  fleeting  pains  in  the  abdomen, 
and  more  or  less  malaise.  This  distress,  however,  is  intestinal,  not 
gastric;  and  the  history  does  not  in  the  least  resemble  that  of  gastric 
ulcer. 

Skin  Diseases. — Certain  affections  of  the  skin,  whose  pathology 
is  still  very  obscure,  arc  at  times  attended  by  gastro-inleslinal  crises. 
This  is  particularly  true  of  those  affections  belonging  to  the  erythema 
group,  and  while  they  arc  more  common  in  children,  in  whom  gastric 
perforations  arc  extremely  rare,  they  are  not  unknown  among  adults. 
The  occurrence  of   ]>urpura,  angeio-ncurotic  cx'dema,  erythema,  or 


Diagnosis  of  Gastric  Ulcer.  95 

urticaria,  with  recurring  colic,  and  often  albumen  in  the  urine,  are  the 
symptoms  most  significant  of  skin  disease. 

Cicatrizing  (Chronic  or  Callous)  Ulcer. — This  form  of  ulcer  is 
characterized  less  by  acute  pain  and  hsematemesis  than  by  persis- 
tent indigestion,  melaena,  which  is  often  overlooked,  and  symptoms 
of  obstruction  of  the  pylorus.  The  vomitus  may  occasionally  be 
streaked  with  blood,  but  the  hemorrhage  is  rarely  large  in  amount, 
except  when  fatal  from  perforation  of  some  large  vessel.  The  pain  is 
not  so  marked  as  in  open  ulcer,  the  area  of  tenderness  is  not  so  well 
defined,  and  vomiting  does  not  occur  so  soon  after  the  ingestion  of 
food.  The  pain  is  much  more  apt  to  be  referred  to  some  other  region 
of  the  body,  particularly  to  the  left  scapular  region,  and  is  more  due 
to  pulling  upon  adhesions  than  to  irritation  of  the  surface  of  the  ulcer. 
Perforation  is  rare,  and  when  it  occurs  is  in  the  immense  majority  of 
cases  either  subacute  or  chronic  in  type,  much  more  frequently  pro- 
ducing perigastric  or  subphrenic  abscess  than  immediate  generalized 
peritonitis.  A  palpable  mass  is  not  unusual  in  a  patient  with  a  callous 
ulcer,  and  may  sometimes  closely  simulate  malignant  disease.  The 
most  characteristic  features,  however,  are  those  of  dilatation  of  the 
stomach,  with  food  stasis,  and  regurgitant  vomiting — subjects  which 
will  be  considered  in  detail  in  a  subsequent  chapter. 

Diagnosis  in  Cases  of  Gastric  Ulcer. — It  scarcely  seems  neces- 
sary after  the  account  of  this  affection  just  given,  to  dwell  at  any  great 
length  upon  its  diagnosis.  Yet  this  is  not  always  an  easy  matter,  in 
spite  of  the  succinctness  with  which  the  symptoms  may  be  detailed. 
The  clinical  history  of  the  patient  is  the  feature  of  the  disease  which  is 
most  constant,  and  which  must,  in  our  judgement,  take  precedence 
over  the  physical  examination,  and  over  diagnosis  by  means  of  labor- 
atory methods.  Too  little  attention  is  commonly  paid  both  by  the 
family  physician  and  the  consultant  to  the  importance  of  eliciting  a 
clear  and  untrammeled  account  of  the  origin  and  progress  of  the 
malady  from  which  the  patient  suffers.  In  cases  of  doubt,  the  atten- 
dant should  return  to  the  charge  again  and  again,  and  should  en- 
deavour, without  putting  upon  the  patient's  tongue  any  false  answers, 
to  obtain  from  him  such  responses  as  will,  when  strung  together  in 
chronological  order,  reveal  the  natural  course  of  the  disease.     Very 


q6         Benign  Diseases  of  the  Stomach  and  Duodenum. 

many  patients  will  have  forgotten  the  earliest  symptoms  from  which 
they  suffered  because  they  were  ignorant  of  their  significance;  and 
it  may  not  be  until  they  have  been  questioned  two  or  three  times  that 
some  event,  such  as  slight  hfematemesis,  seemingly  trivial  in  itself, 
will  rise  again  to  their  memory,  and  perhaps  supply  to  the  history  of 
the  disease  the  missing  hnk  which  so  long  had  been  desired. 

The  physical  examination  must  be  considered  as  merely  con- 
firmatory of  the  clinical  history,  as  previously  elicited;  and  any 
chemical  tests  of  the  stomach  contents  are  of  value  only  as  corrobo- 
rating the  physical  examination.  Blood  examination  may  further 
confirm  the  diagnosis  by  revealing  a  chronic  anaemia.  The  presence 
of  the  normal  leukocytosis  during  digestion  favours  ulcer  rather  than 
carcinoma. 

Differential  Diagnosis. — There  are  few  affections  with  which  a 
case  of  uncomplicated  gastric  ulcer  need  be  confused.  An  exception 
to  this  statement  is  ulcer  of  the  duodenum,  which  in  many  respects  may 
so  closely  resemble  gastric  ulcer  as  to  be  indistinguishable.  Its 
symptomatology  is  so  fully  considered  under  another  section  that  it 
suffices  here  to  recall  the  propriety  of  always  having  in  mind  the  pos- 
sible evidence  of  an  ulcer  in  this  region  in  any  atypical  case  of  sup- 
posedly gastric  ulcer. 

Acute  gastritis  and  gaslro  duodenal  catarrh,  while  possibly  pro- 
ductive of  the  symptoms  of  pain,  tenderness  and  vomiting,  are  affec- 
tions which  may  almost  always  be  traced  to  some  recent  indiscretion 
in  diet.  The  vomiting  does  not  recur  with  any  regularity  after  meals, 
in  the  effort  to  relieve  the  stomach  of  the  j^ain  which  is  present  in  cases 
of  ulcer,  but  is  the  result  of  nearly  constant  nausea,  which  is  charac- 
teristic of  the  inflammatory  nature  of  the  condition.  The  tenderness  is 
diffuse,  not  accurately  localized,  as  is  usual  in  cases  of  gastric  ulcer; 
haimatemesis  occurs  only  in  the  most  excejjtional  cases;  and  jaundice, 
which  is  extremely  rare  in  simple  gastric  ulcer,  is  a  frecjuent  accom- 
paniment of  gastro-duodenal  catarrh.  P'inally,  abstinence  from  food, 
with  other  appropriate  treatment,  quickly  relieves  the  inflammatory 
affection,  while  the  symptoms  of  gastric  ulcer  ])ersist,  or  if  cured 
temporarily  are  prone  to  recur  as  soon  as  energetic  treatment  is  dis- 
continued. 


Diagnosis  of  Gastric  Ulcer,  97 

Hemorrhage  from  the  gastro-intestinal  tract  due  to  other  causes 
than  gastric  ulcer  may  be  extremely  difficult  at  times  to  differentiate 
from  the  latter  affection.  Particularly  of  hsematemesis  is  this  true. 
When  the  blood  is  discharged  from  the  bowel,  although  duodenal  ulcer 
should  certainly  be  considered,  there  are  usually  other  symptoms 
which  will  aid  the  diagnosis.  Enterorrhagia  is  sometimes  the  earliest 
symptom  of  typhoid  fever;  it  is  not  unfrequent  as  an  early  symptom 
of  malignant  changes  in  the  bowel;  but  in  both  of  these,  as  in  almost 
every  other  conceivable  case  of  bleeding  from  the  bowels,  there  is 
almost  invariably  soon  developed  some  other  symptom  or  chain  of 
symptoms  which  at  once  makes  clear  the  nature  of  the  malady. 

Far  different  is  the  case  with  gastrorrhagia  and  hsematemesis. 
It  is  natural  to  assume  that  a  patient  presenting  these  symptoms 
suffers  from  gastric  ulcer;  and  when  all  other  lesions  have  been  ex- 
cluded, the  supposition  seems  justifiable.  The  confusion  of  haemop- 
tysis with  gastric  hemorrhage  is  not  usual,  and  the  difference  in  the 
physical  signs  between  the  gastric  and  thoracic  disease,  as  well  as  the 
frothy  character  of  the  expectorated  blood,  tend  to  make  such  con- 
fusion, if  it  ever  arise,  rather  short-lived. 

A  cause  of  sudden  profuse  hemorrhage  which,  until  recently,  has 
not  received  adequate  consideration,  is  the  rupture  of  varicose  veins 
of  the  stomach  or  of  the  lower  portion  of  the  oesophagus.  It  is  not 
improbable  that  some  of  the  hemorrhages  formerly  attributed  to 
erosions  were  in  reality  due  to  the  rupture  of  varicose  veins.  W. 
J.  Taylor  gives  a  full  discussion  of  this  subject  in  an  article  published 
in  the  Transactions  of  the  College  of  Physicians  of  Philadelphia  for 
1906.  In  many  instances  such  varicose  veins  are  a  prolific  source  of 
gastric  hemorrhage,  unattended  by  evidence  of  disease  elsewhere  in 
the  body.  Preble  collected  sixty  cases  of  fatal  gastro-intestinal 
hemorrhage  due  to  cirrhosis  of  the  liver.  Out  of  these  sixty  cases  the 
oesophagus  was  examined  in  forty- two;  and  among  these  there  were 
found  oesophageal  varices  in  thirty-five  cases,  or  85  per  cent.  The 
source  of  the  hemorrhage,  Preble  states,  was  recorded  in  19  cases, 
occurring  16  times  from  rupture  or  ulceration  of  oesophageal  varices, 
twice  from  ulcers  over  gastric  veins  near  the  cardiac,  and  once  from 
an  erosion  near  the  cardia.  He  thinks  it  probable  that  in  many  of  the 
7 


98  Benign  Diseases  of  the  Stomach  and  Duodenum. 

cases  in  which  ^•ariccs  were  present  minute  ruptures  had  occurred 
which  were  overlooked,  as  they  were  not  tested  by  injection  with  air 
or  fluid.  ''The  veins  of  the  cardiac  end  of  the  stomach  are  part  of  the 
portal  system,  while  those  of  the  oesophagus  are  part  of  the  systemic 
system.  Here,  as  at  the  lower  end  of  the  intestinal  tract,  the  two 
systems  are  connected  by  anastomosing  branches  which,  as  a  rule, 
according  to  Orth  and  Kundrat,  are  too  small  or  too  few  to  contribute 
much  to  the  formation  of  a  collateral  circulation  when  the  portal 
system  is  obstructed.  But  when  this  anastomosis  is  free,  they  become 
an  important  factor,  and  their  dilatation  may  so  completely  com- 


FiG.  18. — W.  J.  Taylor's  Specimen  Showing  Ruptuke  of  a  Varicose  Gastric 

Vein  Near  the  Cardia. 
Note  also  gastro-jejunuostomy  opening,  and  Pagenstcchcr  thread  hanging  loose,  with 
piece  of  undigested  vegetable  fibre  attached. 

pensate  for  the  veins  obstructed  in  the  liver  that  tlie  clinical  course  of 
the  cirrhosis  is  ahered  and  ()l)sciircd  "  (Preble). 

The  blood  in  the  lower  crsophageal  veins  is  returned  to  the  lu-art 
by  way  of  tiie  lower  azygos  minor  \ein,  as  well  as  through  some  of  the 
bronchial  veins;  and,  as  Prel)le  y)()ints  out,  l)eing  intrathoracic  in 
situation,  tliey  "feel  the  negali\e  ])ressure  of  ins])irali()n,  while  at  tlie 
same  time  the  ])ressure  in  the  ])ortal  system  rises  to  fourteen  or  e\'en 
eighteen  milHmetres  of  mercury.  In  this  way  the  l)l()od  is  literally 
aspirated  from  the  coronary  into  the  irsophagcai  x'cins,  and  leads  to 
their  ])ermanenl  dilatation." 


Diagnosis  of  Gastric  Ulcer.  99 

In  patients,  therefore,  where  the  anastomosis  between  the  coronary 
and  the  oesophageal  veins  is  free,  cirrhosis  of  the  liver  may  produce 
none  of  its  usual  symptoms,  such  as  ascites,  enlargement  of  the  spleen 
and  of  the  subcutaneous  abdominal  veins.  Among  the  patients  whose 
records  were  examined  by  Preble,  in  whom  varices  were  present  and 
caused  hemorrhage,  one-third  died  from  hemorrhage  without  any  ac- 
companying sign  of  cirrhosis;  in  one-third  hemorrhage  was  the  first 
symptom,  and  others  followed;  and  in  the  other  third  the  hemorrhage 
was  preceded  by  other  symptoms. 

The  surgeon,  therefore,  should  be  very  cautious  about  undertaking 
operations  on  the  stomach  in  the  case  of  a  patient  who  presents  symp- 
toms merely  of  gastric  hemorrhage,  without  other  evidences  of  ulcer. 
If  the  abdomen  of  a  patient  with  oesophageal  varices  due  to  cirrhosis 
of  the  liver  be  opened,  there  will  usually  be  found  an  increased  amount 
of  peritoneal  fluid,  and  palpation  of  the  liver  may  detect  the  true  con- 
dition. Under  such  circumstances,  probably  the  best  course  will  be 
to  suture  the  omentum  to  the  parietal  peritoneum,  in  the  hope  of  re- 
lieving the  oesophageal  veins  of  some  of  their  pressure.  Certainly  no 
relief  can  be  expected  from  a  gastro- enterostomy.  In  cases  of  post- 
operative hemorrhage  we  believe  with  Dieulafoy  that  the  condition  is 
generally  due  to  a  mild  form  of  sepsis,  and  that  in  fatal  cases  one  or 
more  erosions  or  exulcerations  could  be  found  in  the  gastric  or  in- 
testinal mucosa. 

A  distinction  between  open  ulcer  of  the  stomach  and  gastric 
carcinoma  is  not  usually  difficult;  but  in  certain  cases  of  callous  ulcer 
with  much  thickening  and  many  perigastric  adhesions,  the  diagnosis 
is  often  a  matter  of  considerable  importance  as  well  as  difficulty,  since 
the  question  of  radical  treatment  is  at  once  raised.  The  distinction 
will  be  fully  discussed  under  the  heading  of  pyloric  obstruction  (see 
page  133).  The  duration  of  the  disease  is  the  most  important  factor 
in  differentiating  a  simple  ulcer  from  a  cancer;  but  it  must  not  be 
forgotten  that  while  carcinoma  is  typically  abrupt  in  its  onset,  first 
manifesting  itself  after  forty  years  of  age,  yet  that  it  is  not  unfrequently 
implanted  upon  ulcer,  and  that  a  patient  with  an  ulcer  of  many  years' 
duration  may  have  a  carcinoma  which  has  only  recently  developed, 
but  whose  course,  unchecked,  will  be  quickly  fatal.     The  age  of  the 


100       Benign  Diseases  of  the  Stomach  and  Duodenum. 

patient,  moreover,  is  no  certain  guide  as  to  the  presence  of  cancer. 
As  is  well  known,  the  gastro-intestinal  tract  is  affected  with  malignant 
growths  in  younger  patients  than  is  any  other  region  of  the  body. 

Gall-stone  colic  and  cholecystitis  are  usually  sufficiently  distin- 
guished by  the  location  of  their  symptoms  and  physical  signs,  as  well 
as  by  the  extreme  irregularity  of  the  attacks  of  gall-stone  colic,  which 
bear  no  relation  whatever  to  the  ingestion  of  food,  and  which  recur 
with  no  persistence  after  each  meal,  as  does  the  pain  due  to  gastric 
ulcer.  ^Moreover,  in  the  intervals  of  biliary  cohc  the  digestion  is 
apparently  in  perfect  order,  and  pain  is  absent. 

Prognosis. — The  prognosis  in  cases  of  ulcer  of  the  stomach  may 
be  considered  under  three  headings:  (i)  Untreated;  (2)  Medical 
Treatment;  (3)  Surgical  Treatment.  It  is,  however,  extremely 
difficult  to  obtain  any  accurate  data  as  to  the  percentage  of  deaths  and 
permanent  cures  under  the  first  two  headings ;  and  even  with  surgical 
treatment  wx  must  acknowledge  that  it  is  still  of  too  recent  adoption 
for  us  to  draw  definitive  conclusions. 

It  is  not  likely  that  a  patient  with  an  ulcer  which  produces  symp- 
toms of  any  severity  will  go  untreated.  But  it  must  be  remembered 
that  many  ulcers  are  latent,  and  first  announce  their  presence  by 
copious  hemorrhage  or  lethal  perforation.  Van  Valzah  and  Nis- 
bet,  as  long  ago  as  1900,  were  able  to  find  scattered  through  the  liter- 
ature fifty-eight  cases  of  latent  ulcer,  the  first  manifestation  of  which 
was  perforation. 

But  there  are  many  patients  in  whom  the  symptoms  of  the  disease 
are  subacute  in  character,  and  persist  for  years,  untreated,  until  linally 
some  acute  complication  occurs,  killing  tlicm,  or  at  least  bringing 
them  very  near  death ;  or  if  no  acute  complication  arises,  the  patients 
pass  into  the  class  of  chronic  gastric  ulcer,  with  pyloric  obstruction, 
gastric  dilatation,  or  other  more  serious  affections.  Brinton  gave  the 
mortality  from  all  causes  in  gastric  ulcer  as  50  ])er  cent.;  Lebert  con- 
sidered 10  per  cent,  a  fair  estimate;  while  Robson  and  Aloynihan 
come  to  the  reasonable  conclusion  that  under  medical  treatment  the 
mortality  of  gastric  ulcer  is  at  least  20  per  cent.  This  mortality  they 
divide  between  hemorrhage,  which  kills  5  per  ccnl.jand  perforation, 
which  kills  at  least  15  per  cenl.  of  patients  with  ulcer  of  the  stomach. 


Prognosis  in  Gastric  Ulcer.  loi 

When,  in  addition  to  these  figures,  we  consider  the  other  com- 
pHcations  to  which  patients  with  gastric  ulcer  are  prone,  we  begin  to 
realize  what  an  alarmingly  serious  disease  it  is,  and  how  unsatisfactory 
medical  treatment  must  be  in  a  great  many  cases.  Among  other 
complications  to  which  gastric  ulcer  may  give  rise  must  be  considered, 
in  addition  to  perforation  and  hemorrhage,  pyloric  stenosis,  with  its 
long  train  of  maladies  due  to  dilated  stomach;  hourglass  stomach, 
and  other  results  of  adhesions  and  distortions;  the  transition  of  ulcer 
into  carcinoma  (see  page  271);  subphrenic  abscess;  and  even  pro- 
gressive pernicious  anaemia,  which  is  dwelt  upon  in  particular  by 
Hemmeter. 

That  medical  treatment  may  accomplish  much  in  patients  suffer- 
ing from  open  ulcer  no  one  can  deny.  The  immediate  mortality  of 
the  disease  may  probably  be  reduced  to  10  per  cent,  by  the  best 
medical  treatment.  But  the  treatment  must  be  methodical  and 
energetic.  No  half-hearted  measures  will  suffice.  As  Van  Valzah 
and  Nisbet  say,  "Expectant  treatment  is  a  great  blunder,  for  simple 
ulcer  in  a  vigorous  adult  has  no  'innate  tendency  to  heal,'  and  the 
grave  accidents  which  are  too  often  the  heralds  of  coming  death  occur 
somewhat  regardless  of  the  age,  the  constitution,  and  the  general  state 
of  nutrition.  The  treatment  must  in  every  case  be  immediate, 
methodical,  and  sufficiently  vigorous  to  be  effective.  A  compromise 
may  mean  death  or  irreparable  injury." 

To  consider  at  present  only  the  prognosis  of  open  ulcer  of  the 
stomach,  postponing  that  of  the  callous  or  cicatrized  variety  to  another 
chapter;  it  seems  to  us  that  a  rational  point  of  view  is  the  following: 
To  adopt  in  every  case  energetic  medical  treatment,  by  which  we 
mean  rest  in  bed,  with  local  rest  for  the  stomach,  procured  by  nearly 
total  abstinence  from  mouth  feeding  for  at  least  one  week,  while  the 
patient's  strength  is  supported  by  nutrient  enemata.  A  very  gradual 
return  to  normal  diet  must  be  insisted  upon.  Under  appropriate 
treatment  such  as  this,  the  acute  pain,  the  tenderness,  and  the  re- 
curring hemorrhages  of  open  ulcer  can  almost  invariably  be  checked, 
and  in  a  certain  proportion  of  cases,  smaller  we  believe  than  medical 
men  as  a  rule  admit,  these  patients  will  remain  cured.  Mumford  and 
Stone  have  quite  recently  considered  in  some  detail  these  questions. 


102        Benign  Diseases  of  the  Stomach  and  Duodenum. 

and  conclude  that,  of  patients  treated  by  medical  means  and  ap- 
parently cured  (averaging  about  So  per  cent,  of  the  whole),  probably 
one-half  do  not  remain  cured,  but  have  relapses  of  the  same  disease, 
or  have  some  new  and  more  serious  disease,  such  as  gastrectasis  or 
gastric  carcinoma,  engrafted  upon  the  previously  existing  disease. 
Paterson  has  recently  traced  72  patients  who  after  medical  treat- 
ment were  discharged  from  the  hospital  wards  as  clinically  "cured." 
The  most  recent  cases  had  been  discharged  more  than  two  years 
before  the  investigation  of  their  condition  was  undertaken.  He 
found  that  of  these  72  patients,  only  19  were  permanently  cured; 
the  condition  of  7  was  doubtful;  while  46  were  either  still  suffering 
from  the  symptoms  of  gastric  ulcer  (being  40  in  number),  had  sub- 
mitted subsequently  to  operative  treatment  (5  patients),  or  had 
died  from  gastric  disease.  Thus  less  than  27  per  cent,  were  per- 
manently cured  by  the  medical  treatment  instituted;  and  even  if 
the  uncertain  cases  be  counted  as  cures,  there  still  remain  64  ]ier 
cent,  of  the  patients  uncured  by  medical  treatment.  jNIurdoch 
(1906)  has  reported  more  satisfactory  results :  he  studied  32 
patients  who  had  been  medically  treated  for  chronic  ulcer ;  of 
these,  3  could  not  be  traced,  and  2  had  died  (i  of  aneurism,  and 
I  of  gastric  hemorrhage);  of  those  who  remained,  20,  or  69  per 
cent.,  were  cured  three  years  or  more  after  having  medical  treat- 
ment, 4  were  much  improved,  and  3  were  not  improA'ed  by  the 
treatment  that  had  been  adopted.  In  view  of  these  facts,  therefore, 
we  are  of  the  opinion,  where  the  symptoms  of  open  ulcer  arc  not 
relieved  after  energetic  medical  treatment  lasting  for  several  weeks 
— probably  three  months  should  l)e  the  outside  limit — or  where 
the  disease  recurs  more  than  once  after  being  tem])orarily  checked, 
that  in  such  jjatients  .some  more  radical  treatment  is  recjuired  tlian 
medicine  today  affords.  To  meet  the  same  indications  wlu'cli  are 
])resent  when  these  ca.ses  are  being  Ircaled  medicall}-,  the  surgeon 
offers  other  means.  He  offers  a  i^ermanent  solution  of  the  diffi- 
culty, where  the  ])hysician  has  only  an  iin])erfcct  and  tem])orary 
.solution  available.  The  main  iiidicalion  in  all  cases  of  ()])en  gastric 
ulcer  is  to  reduce  the  hyperacidity  of  the  stomach.  Tlie  physician 
aims  to  bring  this  about   l)y  suppressing  gastric  secretion   ])v  cither 


Prognosis  in  Gastric  Ulcer.  103 

total  or  partial  abolition  of  mouth  feeding.  ]\Ieanwhile  the  patient 
is  given  nutrient  enemata.  Now,  while  nutrient  enemata  are  a 
means  of  treatment  whose  value  is  thoroughly  appreciated  by  the 
surgeon,  it  is  one  whose  value  is  very  often  overestimated.  The 
painstaking  researches  of  Edsall  and  Miller  have  shown  that  even 
under  the  best  conditions  patients  fed  only  with  nutritious  enemata 
are  slowly  starving  to  death ;  that  the  rate  of  excretion  in  such 
patients  always  exceeds  the  rate  of  absorption.  Nor  is  the  secre- 
tion of  gastric  juice  prevented  by  means  of  nutrient  enemata;  for 
repeated  experimentation  has  shown  that  the  presence  of  nutritious 
material  even  in  the  large  bowel  will  reflexly  stimulate  the  gastric 
glands,  and  the  ulcer  will  thus  be  bathed  in  acid  still.  Yet  pa- 
tients who  receive  some  food  by  the  mouth  do  not  do  so  badly  as 
those  who  are  entirely  prohibited  from  this  means  of  nutrition; 
a  fact  which  is  shown  by  the  familiar  statistics  of  Greenough  and 
Joslin:  Of  62  patients  treated  with  no  food  by  the  mouth,  32  per 
cent,  only  were  cured;  while  of  52  patients  who  received  some  food 
by  the  mouth,  44  per  cent,  were  cured.  It  is  true  that  the  latter 
series,  as  pointed  out  by  these  authors,  probably  included  the  less 
severe  cases;  but  even  with  such  an  allowance,  the  conclusion  is 
irresistible  that  the  absolute  starvation  to  which  the  patients  in  the 
former  series  were  subjected  (notwithstanding  their  receiving 
nutrient  enemata)  had  a  direct  tendency  to  delay  or  even  prevent 
their  cure,  by  depressing  their  recuperative  powers.  The  patients 
who  received  no  food  by  the  mouth,  moreover,  remained  a  longer 
time  in  the  hospital,  on  the  average,  evidently  for  the  same  reason 
— failure  of  recuperative  power. 

The  method  of  relief  which  surgery  offers  these  sufferers  con- 
sists in  some  form  of  operation  by  which  the  gastric  secretion  is 
more  or  less  permanently  altered.  The  physiological  results  of 
gastro-enterostomy  have  been  studied  by  Carle  and  Fantino,  by 
Soupault,  by  Paterson,  by  Cameron,  by  Mintz  and  others.  The 
reader  w^ho  desires  to  examine  their  results  in  detail  is  referred  to 
the  original  articles,  references  to  which  are  appended  (p.  129). 
More  recently  Katzenstein  has  studied  its  results  by  means  of  ex- 
periments on  dogs.     He  ascertained  :    (i)  That  after  gastro-enter- 


104       Benign  Diseases  of  the  Stomach  and  Duodenum. 

ostomy  of  any  kind  both  pancreatic  juice  and  bile  passed  freely 
into  the  stomach;  {2)  This  inflow  of  alkaline  fluid  into  the  stomach 
was  continuous  in  the  early  period  after  operation,  but  later  on  the 
inflow  was  periodical  only;  (3)  Some  months  after  the  operation, 
pancreatic  ferment  and  bile  were  demonstrable  in  the  stomach  one 
and  a  half  hours  after  eating  flesh,  but  after  taking  fat  or  water 
they  were  found  there  after  half  an  hour;  (4)  The  results  of  these 
changes  were  diminution  of  acidity  and  of  pepsin  digestion.  From 
these  facts  Katzenstein  concluded  that  gastro-enterostomy  exerted 
a  curative  effect  on  ulcer  by  diminishing  gastric  acidity,  and  he 
suggested  that  the  arrest  of  carcinomatous  growth  sometimes  ob- 
served after  this  operation  might  be  due  to  the  local  action  of  the 
trypsin  of  the  pancreatic  juice.  In  applying  to  man  any  conclu- 
sions drawn  solely  from  animal  experimentation,  we  have  always 
felt  that  great  caution  should  be  employed;  but,  as  practically  the 
same  course  of  events  has  been  observed  clinically,  the  conclusions 
of  Katzenstein  seem  to  us  worthy  of  acceptance.  Even  Hale  White 
admits  that  the  metabolism  of  the  body  is  not  materially  altered  by 
gastro- j  e  j  unostomy . 

The  choice  of  operation  does  not  concern  us  here.  It  will  be 
fully  discussed  under  the  head  of  treatment.  What  we  desire  at 
present  to  learn  is  the  immediate  mortality  of  surgical  treatment, 
and  the  proportion  of  ultimate  and  enduring  cures  that  we  may 
expect. 

We  have  seen  above  that  under  medical  treatment  the  imme- 
diate mortality  is  from  10  to  20  per  cent.  The  mortality  of  untreated 
cases  may  be  estimated  at  from  20  to  50  per  cent.  Mumford  and 
Stone  have  recently  estimated  the  immediate  mortality  under  Ihe 
best  medical  treatment  as  at  least  8  per  cent.  This  is,  if  anytliing 
too  low.  Jkilstrode's  statistics  for  500  cases  of  gastric  ulcer  treated 
medically  from  1897  to  1904,  gave  a  mortality  of  18  per  cent.,  and 
this  reckoning  included  all  cases,  even  the  very  mildest,  on  which  no 
one  has  ever  proposed  to  operate ;  so  that  if  only  the  gravest  cases 
were  considered,  tlic  mortality  under  medical  treatment  would  be 
enormously  increased.  It  may  be  remarked  in  passing  that  the 
.statistics  of  Ave  or  more   \ears  ago  represent  very  accurately  the 


Prognosis  in  Gastric  Ulcer.  105 

most  modern  results  of  medical  treatment,  since  this  has  not 
changed  appreciably  in  that  time;  whereas  surgical  figures  show  a 
constant  progress,  and  statistics  even  four  years  old  can  no  longer 
be  considered  representative  of  the  best  obtainable  results.  The 
surgery  of  the  stomach  is  new — it  is  one  of  the  newest  things  in 
surgery  today;  and  while  the  figures  about  to  be  given  are  the 
most  recent  available,  they  cannot  accurately  represent  the  latest 
and  therefore  the  best  results.  The  average  death  rate  for  gastro- 
enterostomy, or  for  Finney's  pyloroplasty,  which  are  the  operations 
most  frequently  employed  in  these  conditions,  is  as  low  in  the 
average  at  the  present  day,  in  the  hands  of  competent  surgeons,  as 
five  per  cent. 

STATISTICS  OF  OPERATIONS  FOR  BENIGN  DISEASES  OF  THE 

Operator.  Date. 

Crilei5 1908 

Czerny  ^ 1902 

Deaver  ^ 1900-1907 

Hartmann  ^ 1903-1905 

Helferich  * 1905 

Hochenegg  ^ 1906 

Krause  ^ 1906 

Mayo ' 1906 

Morison  ^ 1905 

Moynihan  * 1906 

Power,  D'Arcy  '" 1906 

Robson,  Mayo  '' 1906 

Rotgans  '^ 1906 

Schou  ^^ 1907 

Schloffer" - 1906 

'  Czerny:     Petersen  and  Machol,  Beitr.  z.  klin.  Chir.,  1902,  xxxiii,  297. 

^Deaver:     Records  of  German  Hospital,  Philadelphia,  to  Jan.  i,  1908. 

.^Hartmann:     Lancet,  1906,  November  24. 

^Helferich:     Graf,  Deutsch.  Zeit.  f.  Chir.,  1907,  xc,  365. 

^Hochenegg:     Semaine  Med.,  1906,  October  31. 

^Krause:     Medical  Press  and  Circ,  1906,  Dec.  12. 

'Mayo:     Annals  of  Surgery,  April,  1906. 

*  Morison:     Brit.  Med.  Jour.,  1905,  ii,  777. 

'Moynihan:     Lancet,  1906,  Nov.  24. 

^^ Power,  D'Arcy:     Lancet,  1906,  December  16. 

"Robson,  Mayo:     Brit.  Med.  Jour.,  1906,  ii,  1347. 

'^Rotgans:     Lancet,  1906,  November  24. 

13  Schou:     Zentralbl.  f.  Chir.,  1907,  No.  29,  S.  866. 

i^Schloffer:     Semaine  Med.,  1906,  xxvi,  219. 

i^Crile:     Ohio  State  Med.  Jour.,  1908,  iv,  80. 


STOMACH. 

Number  of  Operations. 

Deaths. 

Mortality. 

56 

I 

1.7  per  cent 

83 

4 

4.8    "       ' 

91 

8 

8.7    "       ' 

47 

3 

6.3    "       ' 

86 

7 

8.1    "       ' 

94 

6 

6.4    "       ' 

55 

5 

9.0    "       ' 

307 

19 

6.2    " 

27 

I 

3-7    "       ' 

334 

21 

6.2    " 

41 

3 

7-3    "       ' 

322 

10 

3.1    "       ' 
5.0    "       ' 

54 

3 

5-5    "       ' 

53 

2 

3.8    "       ' 

io6        Benign  Diseases  oi  the  Stomach  and  Duodenum. 

Ahhough  the  statistics  from  general  hospitals  are  by  no  means  so 
good  as  those  obtained  by  individual  surgeons,  yet  they  are  bound 
to  improve  as  the  average  surgeon  becomes  more  skillful  both  in 
selecting  his  cases  for  operation,  as  well  as  in  the  actual  perform- 
ance of  the  operation  itself.  French  reported  from  Guy's  Hospital 
47  gastro-enterostomies  for  benign  disease,  with  13  deaths,  a  mortality 
of  23.4  per  cent.;  while  in  St.  Bartholomew's  Hospital  Gask  found 
6  deaths  among  35  gastro-enterostomies  for  benign  disease,  a  death 
rate  of  17.1  per  cent.  The  figures  of  some  surgeons  show  an  almost 
vanishing  mortality:  Mayo  (1906)  had  a  series  of  167  gastro-enter- 
ostomies for  all  causes,  with  only  i  death.  Mayo  Robson  had  only 
2  deaths  among  112  posterior  gastro-jejunostomies  for  benign  dis- 
ease in  his  pri^•ate  practice  up  to  1906.  Moynihan,  in  the  same  year, 
reported  248  posterior  gastro-jejunostomies  for  benign  disease  with 
only  2  deaths,  a  mortality  of  0.8  percent.;  and  there  had  been  no 
deaths  among  the  last  151  such  operations.  J.  B.  Deaver  has  reported 
a  series  of  40  operations  for  benign  diseases  of  the  stomach,  with 
only  I  death  (2.5  per  cent,  mortality);  and  has  since  then  had  a 
series  of  70  operations  with  only  2  deaths,  a  death  rate  of  2.85  per  cent. 

It  must  be  remembered,  moreover,  that  the  figures  for  the  surgical 
side  of  the  argument  include  not  only  operations  done  on  stomachs 
comparatively  slightly  diseased,  but  also  many  operations  done  on 
stomachs  very  extensively  diseased — dilated,  distorted,  or  contracted 
— by  chronic  ulceration;  that  the  resistance  of  such  patients  may  be 
expected  to  be  less  than  that  of  those  in  the  class  we  are  now  consider- 
ing, and  that  the  operative  mortality  is  constantly  lessening  as  sur- 
geons become  more  expert  and  as  their  experience  increases.  This 
jjrogressive  impro\-ement  is  well  shown  in  the  figures  puljlished  by 
Hartmann,  with  characteristic  courage:  His  first  series  of  operations, 
done  while  he  was  assistant  to  Terrier,  com])rised  21  gastro-enteros- 
tomies, with  5  deaths,  a  mor1ali(\'  of  23.7  |)ei-  cent.,  a  deatli 
rate  which  is  practically  the  same  as  that  re])orted  l)y  French 
as  occurring  in  Guy's  Hospitak  Hartmann's  second  series  of 
o]>erations,  embracing  those  done  from  the  time  lie  ceased 
to  be  a.ssistant  to  Terrier  until  Jan.  i,  1903,  consisted  of  34 
gastro-enterostomies,    with     3    deaths,    a     mortality    of     8.8     per 


Prognosis  in  Gastric  Ulcer.  107 

cent.;  while  his  latest  reported  series,  running  from  1903  to 
1905,  including  47  gastro-enterostomies,  with  only  3  deaths, 
showed  a  mortality  of  6.3  per  cent.  If,  then,  to  these  factors  of 
improvement  in  the  surgical  treatment  itself,  we  add  that  impor- 
tant one  of  resort  to  surgical  treatment  before  the  patient  has  be- 
come a  physical  wreck,  the  contrast  between  the  success  of  sur- 
gical and  the  ultimate  failure  of  medical  treatment  becomes  even 
more  marked.  Hartmann  gives  the  following  interesting  figures, 
which  for  the  credit  of  physicians  are  not,  we  are  happy  to  say, 
very  recent.  In  cases  of  gastric  disease  seen  and  treated  primarily 
by  himself  and  his  colleagues — surgeons — the  mortality  of  opera- 
tion was  two  per  cent.;  but  in  a  series  of  cases  which  had  been 
primarily  treated  medically,  and  which  were  later  referred  to 
Hartmann  by  their  physicians,  the  mortality  of  operation  was 
twenty-four  per  cent.  The  two  series  of  cases  included  sixty 
patients.  Kocher  writes:  "The  majority  of  practitioners  do  not 
sufficiently  realize  what  brilliant  results  are  to  be  obtained  by 
operative  means  in  chronic  affections  of  the  stomach,  commonly 
known  as  gastric  catarrh.  Not  only  can  the  numerous  dangers  of 
ulcerating  affections  of  the  stomach,  such  as  hemorrhage,  perfora- 
tion, transition  into  cancer,  be  prevented,  but  the  disease  and  its 
results   may   be    so   rapidly  and  certainly  cured   that  the    medical 

treatment  of  obstinate  cases  must  be  put  in  the  background 

The  pain  in  the  stomach  disappears  immediately  after  the  opera- 
tion. This  is  the  invariable  rule The  patient  does  not  re- 
quire to  pay  any  further  attention  to  the  nature  of  his  food.  The 
vomiting  disappears.  The  bowels  become  regular.  Repeated 
investigation  of  the  gastric  contents  shows  that  there  is  a  pro- 
gressive improvement  in  the  process  of  digestion;  hyperacidity 
diminishes;  if  too  little  acid  is  present,  it  becomes  increased,  a 
statement  which  is  in  accord  with  Steudel,  Carle  and  Fantino, 
Kausch,  Hartmann,  Soupault,  and  Mintz."  Such  words  as  these, 
from  a  surgeon  such  as  Kocher,  who  weighs  well  what  he  writes, 
and  knows  whereof  he  speaks,  should  be  instilled  into  the  mind  of 
every  medical  man  who  has  cases  of  chronic  gastric  indigestion 
under  his  care. 


io8       Benign  Diseases  of  the  Stomach  and  Duodenum. 

If  the  immediate  resuhs  of  surgical  treatment  are  such  as  have 
been  described,  what  are  the  ukimate  resuhs  ?  Is  this  condition 
of  improvement  maintained  ?  Are  the  cures  permanent  ?  A  de- 
cision in  figures  is  not  in  this  instance  so  easily  reached.  This 
is  true  not  only  because  of  the  difficulty,  which  always  exists,  of 
tracing  hospital  patients  after  operation ;  but  also  because  the  very 
recent  adoption  of  surgical  treatment  for  these  patients  precludes 
the  possibility  of  most  of  them  having  post-operative  histories  of 
suflScient  duration  to  be  c|uoted  authoritatively  as  ultimate  results. 
Yet  the  following  may  be  given  as  the  results  in  patients  who 
have  been  traced  for  from  one  to  three  years  or  more  after  operation. 

END  RESULTS  OF  OPERATIONS   FOR  BENIGN  DISEASES  OF  THE 

STOMACH. 

Operator.                                             Cases  Traced.  Cured, 

Mayo,  (1908) 234  189  80.7  percent. 

Moynihan,  (1908) 247  211  85.42  " 

Czerny,  (1902)    53  44  83.0  " 

Robson 96  89  92.7  " 

Deaver,  (1900-1907) 64  49  76.5  " 

Deaver,  (1905-1907)     31  26  83.87  " 

Paterson,  (collective  statistics)    116  109  93.9  " 

Helferich,  (1905)    56  41  73.3  " 

Among  Czerny's  patients,  41  were  cured,  3  were  greatly  im- 
proved, 6  had  recurrence,  and  3  had  died  of  cancer.  Among  the 
seven  patients  of  Mayo  Robson  who  were  not  cured  by  the  opera- 
tion, cancer  developed  in  4,  relapses  occurred  in  2,  and  in  one 
patient  the  operation  had  not  produced  even  a  temporary  relief  of 
symptoms.  Of  the  senior  author's  own  cases,  64  of  which  were 
traced,  37  (58.0  per  cent.)  had  absolutely  no  gastric  symptoms 
after  operation,  and  9  (14.0  per  cent.)  were  markedly  improved; 
6  (9.4"  per  cent.)  were  unimproved  by  the  operation;  3  (4.7  per 
cent.)  had  been  cured  but  had  died  of  intercurrent  disease;  and  9 
had  died  at  varying  intervals  since  leaving  the  hospital  from  the 
original  ga.stric  lesion  (2  proljably  of  cancer),  or  from  some  late 
complication  (intestinal  obstruction,  vicious  circle),  indirectly  caused 
by  tiie  stomach  condition.  Denechau  lias  recently  reported  his 
study  of  the  end  results  of  gastro-enterostomy  for  benign  disease, 
in  104    patients,  operated    on    l)y  different    surgeons.     He    found 


Prognosis  in  Gastric  Ulcer.  109 

"satisfactory"  results  in  54  per  cent.,  moderately  good  results  in 
38  per  cent.,  and  bad  results  (no  improvement)  in  only  7  per  cent, 
of  these  patients. 

Paterson  has  recently  traced  the  subsecjuent  history  of  116 
patients  who  had  been  operated  on  by  gastro- enterostomy  at  periods 
varying  from  two  to  nineteen  years.  He  concludes  that  over  85 
per  cent,  are  completely  relieved,  and  7  per  cent,  almost  completely 
relieved,  thus  giving  less  than  7  per  cent,  of  cases  in  which  the 
results  were  wholly  unsatisfactory.  He  found,  moreover,  if  from 
this  series  were  excluded  those  cases  in  which  the  anastomotic 
opening  was  small  or  in  which  some  mechanical  appliance  was  used 
to  effect  the  anastomosis,  that  the  proportion  in  which  the  result 
had  been  completely  satisfactory  was  92  per  cent.  This  is  cer- 
tainly a  favorable  showing  compared  to  relapses  in  50  per  cent,  or 
more  of  patients  treated  by  medical  means.  And  it  is  our  candid 
opinion  that  these  figures  give  a  fair  idea  of  the  surgical  practice 
of  today — the  statistics  of  a  few  years  ago  were  not  so  good ;  those 
of  this  year  are  better  than  those  of  last,  and  those  of  next  year  will 
be  better  yet.  Surgical  treatment  allows  95  to  98  per  cent,  of  these 
patients  to  recover.  Medical  treatment  allows  75  to  80  per  cent,  to 
recover.  Surgery  permanently  cures  practically  every  patient  who 
recovers.  Medicine  permanently  cures  only  30  to  40  per  cent,  of 
its  patients.  Medical  treatment  is  long  and  uncertain.  Surgical 
treatment  is  rapid  and  sure. 

We  do  not  wish,  however,  to  be  understood  as  urging  surgical 
intervention  in  every  case  of  gastric  ulcer.  As  has  already  been 
stated,  medical  treatment  should  always  first  be  tried,  and  only 
when  methodical  and  energetic  medical  treatment  has  failed  to  cure 
the  patient,  after  it  has  been  persisted  in  for  a  reasonable  time,  or 
when  several  temporary  cures  have  resulted  in  ultimate  relapses, 
only  then,  we  repeat,  is  surgical  treatment  to  be  considered  in 
patients  with  acute,  actively  ulcerating  lesions.  In  ulcers  such  as 
these,  it  is  mainly  on  account  of  the  complication  of  hemorrhage 
that  the  surgeon's  advice  is  sought.  Perforation  is  universally 
acknowledged  to  call  for  surgical  intervention  at  the  earliest  pos- 
sible moment.     But  in  regard  to  hemorrhage  there  is  still  dispute. 


no       Benign  Diseases  of  the  Stomach  and  Duodenum. 

Prognosis  in  Cases  of  Gastric  Hemorrhage.  As  was  pointed 
out  in  connection  with  the  symptomatology  of  gastric  ulcer,  there 
are  several  distinct  varieties  or  types  in  which  bleeding  from  gastric 
ulcers  occurs.  The  hemorrhage  may  be  profuse  and  overwhelm- 
ing; in  such  cases  it  has  usually  been  found  to  be  due  to  a 
very  small  ulceration  into  an  arteriole  or  venule.  This  form 
of  hemorrhage  is  not  readily  amenable  to  surgical  treatment,  and 
usually  subsides  by  medical  measures,  such  as  astringents,  absolute 
rest,  and  the  local  application  of  ice.  The  truly  alarming  hemor- 
rhages are  those  which  are  frequent  and  slight  in  amount,  gradually 
sapping  the  vitality,  and,  because  often  undetected,  causing  a 
profound  anaemia.  Occult  blood  in  the  faeces  may  be  the  only 
evidence  of  this  recurring  bleeding.  For  the  relief  of  bleeding 
such  as  this,  medical  measures  are  of  no  avail.  The  bleeding 
persists,  the  patient  loses  ground,  becomes  wasted,  anaemic,  thirsty, 
feverish.  The  descent  may  be  easy,  but  it  is  so  merely  because  it  is 
gradual.  It  is  none  the  less  progressive  and  sure.  What  is  lost 
is  not  regained,  and  the  attending  physician  will  realize,  perhaps 
too  late,  that  the  decline  into  which  his  patient  has  fallen  is  not 
only  irremediable  by  medical  measures,  but  may  even  have  reached 
the  stage  where  the  shock  of  an  operation  will  kill.  Surgery — suc- 
cessful surgery — cannot  be  done  on  patients  who  have  no  iDlood; 
and  it  is  the  physician's  duty  to  learn  before  it  is  too  late  that  only 
surgery  can  afford  relief.  And  it  can  be  said  without  any  hesi- 
tancy whatever,  that  when  such  patients  are  operated  on  in  good 
time  they  are  restored  to  hcaltli  and  happiness  with  a  regularity  of 
success  which  is  one  of  the  greatest  triumphs  of  modern  surgery. 

The  other  form  of  hemorrhage  to  which  patients  with  open 
ulcer  are  liable,  occurs  more  frequently  than  that  just  mentioned, 
and  is  characterized  l)y  the  intermittent,  and  l)y  no  means  regular, 
occurrence  of  hcX-matemcsis.  The  vomitus  may  at  times  be  only 
streaked  with  blood,  or  there  may  ])e  an  attack  of  vomiting  of 
nearly  pure  l)l()()d,  occurring  once  in  six  weeks  or  two  months,  or  even 
less  often.  In  pronounced  and  recurrent  liemorrhage  the  patient 
fails  in  health  so  rapidf\-  that  radical  measures  are  as  a  rule  will- 
ingly undertaken;   l)ut   in  tlu' le.ss  severe  cases  of  ha-matcmesis  the 


Prognosis  in  Gastric  Hemorrhage.  iii 

strength  may  be  partiaUy  regained  in  the  intervals,  so  that  the  ap- 
pearance of  health  is  maintained  for  some  time;  and  the  patient, 
and  the  physician  as  well,  is  often  deluded  into  thinking  that  oc- 
casional vomiting  of  blood,  with  annoying  though  rather  mild 
indigestion  during  the  intervals,  is  less  of  an  evil  than  would  be 
resort  to  a  surgical  operation.  Could  such  persons  know  the  uni- 
formity with  which  such  symptoms  are  relieved  by  an  operation 
they  would  be  eager  for  its  adoption. 

Case. — Mrs.  S.  W.,  aged  37  years,  admitted  to  the  German 
Hospital  December  7,  1905.  In  June  1905  this  patient  had  been 
treated  in  the  medical  wards  of  the  German  Hospital  for  severe 
haematemesis,  having  vomited  2000  cc.  of  nearly  pure  blood.  She 
had  also  blood  in  her  stools.  Her  haemoglobin  was  25  per  cent. 
She  did  well  under  medical  treatment,  and  refused  operation  when 
she  became  strong  enough  in  our  judgment  to  undergo  one.  She 
returned  to  her  home,  and  lived  in  comparative  comfort  until 
December,  1905,  when,  after  feeling  uncomfortable  and  ill  at  ease 
for  a  few  days,  she  suddenly  vomited  1500  cc.  of  bright  blood.  She 
w^as  at  once  brought  to  the  German  Hospital,  and  soon  after 
admission,  on  December  7th,  she  vomited  2000  cc.  of  blood. 
She  was  nearly  exsanguinated,  but  after  receiving  3500  cc.  of  saline 
solution  intravenously,  appeared  somewhat  improved.  Her  haemo- 
globin was  43  per  cent,  on  Dec.  8th.  By  the  13th  it  had  fallen  to 
31  per  cent.,  in  spite  of  energetic  medical  treatment.  On  December 
i6th,  a  posterior  gastro-jejunostomy  with  no  loop  was  done,  and  the 
patient  stood  the  operation  well.  Two  days  later,  however,  on 
December  i8th,  she  died  of  exhaustion,  with  no  further  bleeding 
from  the  stomach. 

Evidently  in  this  patient  the  operation  was  done  too  late  to  be 
of  any  service;  she  might  as  well  have  died  without  an  operation. 
For  as  has  already  been  remarked  successful  surgery  cannot  be 
done  on  patients  who  have  no  blood,  and  the  case  of  this  patient  is 
a  striking  example  of  the  truth  of  this  statement,  and  teaches  a 
useful  lesson. 

The  prognosis  in  cases  of  gastric  perforation  depends  al- 
most entirely  on  the  promptness  and  efficiency  with  which  operative 
treatment  is  undertaken.  The  results  of  operation  for  this  con- 
dition will  be  fully  discussed  under  the  subject  of  treatment   (page 


112       Benign  Diseases  of  the  Stomach  and  Duodenum. 

122);  and  it  remains  at  the  present  time  only  to  say  a  few  words  in 
reference  to  certain  other  circumstances  which  are  held  to  bear 
some  relation  to  the  prognosis.  C.  Brunner  lays  stress  on  the  in- 
fluence exerted  on  the  prognosis  by  the  amount  of  hydrochloric 
acid  in  the  stomach  at  the  moment  of  perforation.  The  prognosis, 
he  finds,  is  most  fa\'ourable  when  the  hydrochloric  acid  is  most 
abundant,  that  is  from  one  to  one  and  a  half  hours  after  meals; 
since  under  these  circumstances  the  gastric  contents  are  less  septic 
than  immediately  (one-quarter  to  one-half  an  hour)  after  meals, 
at  which  period  of  digestion  the  amount  of  hydrochloric  acid  in  the 
stomach  is  extremely  slight,  and  peritonitis  therefore  more  likely. 
Of  course  perforation  of  an  empty  and  nearly  sterile  stomach  is  so 
much  the  less  dangerous.  The  very  great  fatality  which  attends 
perforation  in  cases  of  gastric  cancer  is  to  be  explained,  according 
to  C.  Brunner,  bv  the  septic  nature  of  the  stomach  contents  due  to 
the  absence  of  hydrochloric  acid. 

Treatment. — Having,  in  the  previous  paragraphs,  attempted 
to  show  which  cases  of  gastric  ulcer  should,  and  which  should  not 
be  subjected  to  operation,  it  now  becomes  our  duty  to  attempt  to 
reach  a  decision  as  to  what  special  form  of  operation  is  to  be  em- 
ployed for  the  relief  of  the  conditions  already  described.  The 
technical  details  of  the  operations  discussed  will  be  found  described 
in  Chapter  XIV. 

Under  the  general  term  gastro-enterostomy  (an  anastomosis 
between  stomach  and  bowel)  may  he  included  the  operation  of 
Pyloroplasty  and  Finney's  modification  of  the  same,  known  some- 
times by  the  cumbrous  name  of  gaslro-pyloro-duodcnostomy,  as  well 
as  Kocher's  lateral  gasiro-duodenoslomy,  and  the  many  and  various 
modifications  of  gaslro-jejunostomy.  Of  these  procedures  there  are 
only  two — Finney's  pyloroplasty,  and  gastro-jejunostomy — which 
in  our  o[)inion  merit  serious  consideration.  And  inasmuch  as  the 
same  oj)erations  arc  emyjloyed  in  other  affections  of  the  stomach, 
which  will  be  described  in  subset iiicnl  cliapters,  it  will  Ije  most  con- 
venient to  discuss  at  some  length,  in  the  ])resent  place,  the  various 
inherent  advantages  and  disadvantages  of  these  o])erations.  Py- 
lorodiosis,  or  digital  divulsion  of  the  pylorus,  performed  by  Loreta 


Operations  for  Gastric  Ulcer.  113 

in  1882,  may  be  dismissed  without  further  consideration  in  this  con- 
nection. The  question  of  its  adoption  in  cases  of  hyperemesis 
lactantium  is  discussed  in  connection  with  that  subject  at  page 
139.  Hahn's  modification  of  the  same  operation,  by  digital  divul- 
sion  without  opening  the  stomach,  may  also  be  dismissed  without 
further  mention,  both  being  operations  whose  futility  and  danger 
have  long  been  recognized. 

Pyloroplasty  as  modified  by  Finney  (1902)  is  really  an  extension 
of  the  Heineke-Mikulicz  operation.  As  Mikulicz  stated  before  the 
Philadelphia  Academy  of  Surgery,  in  1903,  the  usual  illustrations  of 
pyloroplasty  given  in  the  text  books  do  not  accurately  represent 
the  operation,  as  the  incision  should  be  made  much  longer,  so  as 
to  extend  both  into  the  stomach  and  the  duodenum,  and  on  the 
lower  rather  than  the  anterior  wall  of  the  pylorus,  thus  approach- 
ing very  closely  to  the  more  elabourate  operation  proposed  by 
Finney.  The  theoretical  advantages  of  such  an  operation  are  many; 
the  practical  drawbacks  are,  at  least  so  it  seems  to  us,  even  more 
numerous  and  weighty.  It  is  true  that  by  this  method  the  normal 
gastro-intestinal  channel  is  not  altered,  the  ingested  food  passing  at 
once  from  the  stomach  into  the  duodenum,  as  in  the  natural  state; 
it  is  true  that  the  operation  is  not  usually  difficult  to  perform,  and 
that  the  subsequent  developement  of  regurgitant  vomiting  is  very 
unusual  if  not  altogether  unknown;  it  may  also  be  admitted  that 
the  enlargement  of  the  pyloric  end  of  the  stomach  so  much  in  a  down- 
ward direction  will  secure  to  the  ulcerated  area  all  the  benefits  which 
are  now  believed  to  result  after  lateral  gastro-jejunostomy  from  the 
admixture  with  the  gastric  secretion  of  bile  and  pancreatic  juice, 
and  that  Finney's  operation  will  also  render  the  evacuation  of  the 
stomach  more  easy  than  will  resort  to  a  simple  pyloroplasty.  But  in 
spite  of  all  these  advantages,  there  remain  in  our  opinion  very  serious 
disadvantages  which  have  not  as  yet  been  overcome.  In  the  first 
place  the  rate  of  mortality  is  higher  than  is  that  of  gastro-jejunostomy, 
even  in  Finney's  own  hands.  Finney  (1908)  reported  48  operations 
by  his  method,  with  4  deaths  (none  directly  due  to  the  operation),  a 
mortality  of  8.3  per  cent.  Mayo  in  1905  reported  58  operations  by 
Finney's  method  with  4  deaths,  a  mortality  rate  of  6.9  per  cent. 


114       Benign  Diseases  of  the  Stomach  and  Duodenum. 

The  uhimate  results,  moreover,  have  been  less  satisfactory  than 
those  of  gastro-jejunostomy,  except  when  the  cases  for  operation  have 
been  very  carefully  selected.  It  is  needless  to  say  that  it  is  this  very 
selection  of  proper  cases  which  is  the  most  difficult  part  of  surgery. 
The  presence  of  scar  tissue  at  the  pylorus  renders  it  unfit  for  plastic 
procedures;  and  the  existence  of  dense  adhesions  makes  the  operation 
not  only  difficult  but  dangerous.  It  should  be  stated,  how^ever,  that 
Finney  lays  great  stress  upon  the  importance  of  thorough  separa- 
tion of  all  adhesions,  and  even  regards  this  step  of  the  operation  as  a 
requisite  for  success;  and  it  must  be  admitted  that  failure  has  proba- 
bly in  many  instances  resulted  from  neglect  to  carry  out  this  injunc- 
tion rather  than  from  any  inherent  fault  in  the  operation  itself. 
The  ultimate  results  in  Finney's  own  hands  appear  to  have  been 
quite  satisfactory;  he  traced  19  patients  who  had  been  operated  on 
for  open  ulcer  or  for  pyloric  stenosis,  and  found  that  in  none  had 
there  been  a  return  of  symptoms;  of  7  dyspeptics  traced,  4  were 
cured,  I  was  improved,  and  2  had  died;  2  patients  operated  on  for 
gastro-succorrhoea  were  improved;  and  of  6  neurotic  patients 
traced,  2  were  cured,  i  was  improved,  and  3  were  not  improved. 
Rutherford  Morison  (1905)  traced  28  patients  on  whom  he 
had  operated  by  Finney's  method  of  pyloroplasty:  12  were  per- 
fectly well;  TO  had  occasional  attacks  of  stomach  trouble;  6 
patients  had  dchnitc  recurrence  of  the  old  symptoms,  but  4  of 
those  were  permanently  cured  by  subsequent  gastro-jejunostomy. 
The  average  period  of  relief,  he  found,  after  Finney's  operation, 
was  between  4  and  5  years;  and  in  the  4  patients  in  whom  subse- 
quently he  did  gastro-jejunostomy,  the  recurrence  of  symptoms 
was  due  not  to  contraction  of  the  newly  formed  pylorus,  but  to 
fresh  ulceration.  Among  Mayo's  58  patients  there  were  only  two 
(3.4  per  cent.)  secondary  o])crations  required,  tliese  being  for 
chronic  regurgitation  of  bile  into  the  stomach  through  too  large 
an  opening;  a  record  which  .shows  that  not  only  were  his  cases 
carefully  .selected,  but  that  the  technical  details  of  the  operation 
were  carried  out  with  .scruy)ulous  care.  In  our  opinion  it  is  an 
o[)eration  which  should  be  limited  to  ])atients  without  marked 
pyloric  stenosis,    with    good    motor    ])ower,    where  perigastritis  is 


Operations  for  Gastric  Ulcer.  115 

absent,  and  where  the  pylorus  is  not  involved  in  cicatricial  tissue. 
It  will  be  seen  therefore,  that  there  are  very  few  cases  indeed 
in  which  we  deem  this  operation  advisable.  Adhesions  are  na- 
ture's safeguard,  and  should  be  treated  with  respect.  The  surgeon 
who  attempts  the  operation  of  gastrolysis  will  fail  to  secure  relief 
in  ninety-nine  cases  for  the  one  case  in  which  a  cure  results.  Too 
often  the  breaking  up  of  adhesions  only  causes  the  reformation  of 
adhesions  which  are  thicker  and  more  dense.  In  not  a  few  casep 
the  adhesions  are  on  guard  over  a  threatening  perforation  or 
over  one  which  had  perforated  before,  subacutely  or  chronically. 
In  such  cases  injudicious  destruction  of  the  adhesions  may  open  up 
a  perforation  into  the  stomach  which  it  may  be  impossible  to  close 
by  suture,  and  in  any  event  this  procedure  will  subject  the  patient 
to  the  risk  of  septic  peritonitis  from  the  unexpected,  and  at  times 
undiscovered,  extravasation  of  gastric  contents.  The  safer  course 
is  to  perform  a  gastro-jejunostomy  in  a  healthy  portion  of  the 
stomach  wall,  and  leave  nature's  barriers  undisturbed.  The  more 
marked  the  pyloric  stenosis,  the  more  certain  are  the  benefits  to  be 
derived  from  gastro-jejunostomy;  and  where  the  pylorus  is  much 
obstructed  it  is  involved  in  cicatricial  tissue,  and  is  an  extremely 
unsuitable  site  for  direct  incision  and  suture.  Stitches  do  not  hold 
well  in  scar  tissue,  and  scar  tissue  does  not  lend  itself  so  readily  to 
an  anastomotic  operation  as  does  normal  serous  tissue,  both  because 
of  rigidity  and  of  the  lack  of  blood  supply.  Yet  in  cases  such  as 
those  recently  reported  by  MouUin,  in  which  the  pylorus  was  an 
obstructive  factor  without  being  ulcerated  or  the  seat  of  cicatricial 
tissue,  Finney's  operation  may  prove  of  value. 

Gastro-jejunostomy,  on  the  other  hand,  has  been  proved  by 
clinical  experience,  the  true  criterion  of  success,  to  fulfill  most  ad- 
mirably the  indications  in  the  surgical  treatment  of  gastric  ulcer. 
The  death  rate  immediately  due  to  this  operation  is  extremely 
low — varying  from  three  to  less  than  one  per  cent,  in  the  hands  of 
experienced  operators,  and  averaging  probably  not  much  over  ten 
per  cent,  in  collective  statistics.  The  main  objection  to  the  opera- 
tion, as  applied  to  the  cure  of  open  ulcer,  without  marked  pyloric 
stenosis,  is  that  the  food-stuffs  are  in  many  instances  prone  to  pass 


Ii6       Benign  Diseases  of  the  Stomach  and  Duodenum. 

out  of  the  stomach  still  by  way  of  the  diseased  pylorus  rather  than 
to  escape  by  the  newly  formed  anastomotic  opening  at  the  greater 
curvature;  thus  permitting  the  developement  of  a  vicious  circle. 
But  where  the  pylorus  is  patent,  this  difficulty  can  be  readily  over- 
come by  ligation  of  the  pylorus,  thus  rendering  the  passage  through 
the  new  opening  easier  for  the  stomach  contents  than  it  would  be 
when  the  pylorus  opposed  no  special  barrier  to  their  progress. 
If  we  accept  the  idea  of  Roux  of  Lausanne  and  others  as  to  the 
curative  value  of  the  direct  action  of  the  duodenal  secretions  on 
open  gastric  ulcer,  there  will  be  no  reason  in  seeking  to  occlude  the 
pylorus.  The  discussion  of  the  merits  of  the  different  methods  of 
performing  gastro-jejunostomy  will  be  postponed  to  Chapter  XIV. 

There  still  remains  for  consideration  the  treatment  of  gastric 
ulcers  by  excision.  Originally  advocated  by  Rydygier,  it  is  a 
method  which  quickly  fell  into  disrepute,  owing  to  its  enormous 
mortality.  But  in  the  last  few  years  it  has  again  become  popular 
with  some  surgeons  (Maydl,  Jedlicka,  Ali  Krogius,  Rodman, 
Brechot  and  others),  chiefly  on  the  ground  that  it  acts  as  a  pre- 
ventative of  carcinomatous  degeneration,  but  also  because  it  is 
claimed  that  excision  of  the  ulcer,  or  even  if  necessary  of  the  whole 
ulcer  bearing  area,  obviates  the  occurrence  of  subsequent  hemor- 
rhage or  perforation,  calamities  which  are  not  entirely  unknown 
even  after  subsidence  of  symptoms  caused  by  a  gastro-enterostomy. 
On  the  other  hand  the  facts  remain,  that  (i)  the  immediate  mortality 
of  excision  is  higher,  being  5  to  10  per  cent.,  instead  of  i  to  3  per  cent., 
in  experienced  hands,  as  it  is  in  the  case  of  gastro-jejunostomy; 
that  (2),  in  the  second  place,  gastric  ulcers  arc  frequently  multiple, 
and  while  one  or  two  may  be  removed,  others  are  nearly  invariably 
overlooked;  that  (3)  even  should  all  the  existing  ulcers  be  readily 
discoverable,  their  removal  may  ])c  impossible  without  the  per- 
formance of  a  gastrectomy  of  prohibitory  extent;  that  (4)  after 
the  excision  of  the  suspected  ulcer  or  ulcers  fatal  hemorrhage  and 
perforation  have  occurred  from  ulcers  which  were  left  (BiHroth, 
Eiselsberg,  Mayo  Robson  and  others);  and  linall}-  the  (|uestion  of  the 
line  to  be  drawn  between  benign  and  malignant  affections  of  the 
stomach  is  sometimes  very  (hTficuh  if  not  indeed  impossible  to  decide 


Operations  for  Gastric  Ulcer.  117 

by  microscopical  studies  alone.  This  matter  of  malignant  degenera- 
tion or  carcinomatous  implantation  in  gastric  ulcers  will  be  discussed 
at  length  in  connection  with  the  aetiology  of  gastric  carcinoma ;  but  it 
seems  fair  to  conclude  that  microscopical  errors  may  have  been  made 
in  some  instances  where  gastric  ulcers  have  been  said  to  have  presented 
evidences  of  incipient  malignancy,  just  as  clinical  errors  have  been 
committed  in  condemning  to  an  early  grave  patients  with  large  pyloric 
tumors  seemingly  characteristic  of  cancer,  which  tumors  have  grad- 
ually and  quietly  melted  away  after  gastro-jejunostomy  and  other  pal- 
liative operations.  Such  cases  have  been  observed  by  Terrier,  Bidwell, 
Deaver,  Wallis,  Eiselsberg,  Robson,  Demoulin  and  Tufher,  Moynihan, 
Pantzer,  and  others.  Deaver's  patient,  operated  on  as  a  last  resort 
by  anterior  gastro- enterostomy  for  a  supposedly  cancerous  mass,  is 
still  in  excellent  health,  more  than  six  years  after  the  operation.  So 
that  it  seems  not  unreasonable  to  argue  that  a  palliative  operation 
might  have  been  equally  successful  in  permanently  curing  gastric 
ulcers  which  presented  no  outward  signs  whatever  of  malignancy. 
Yet  Jedlicka  argues  very  positively  in  favour  of  excision  of  benign 
ulcers.  Following  his  late  master,  Maydl,  he  records,  during  the 
period  from  1891  to  1904,  34  gastric  or  pyloric  resections  for  benign 
disease,  with  2  deaths,  a  mortality  of  a  little  less  than  6  per  cent.  His 
microscopical  studies  (confirmed  in  most  cases  by  Hlava)  showed  that 
of  his  patients  whose  stomachs  were  resected  for  gastric  ulcer,  sup- 
posedly benign,  no  less  than  26  per  cent,  had  commencing  malignant 
degeneration.  He  points  out,  moreover,  that  of  the  14  patients  whose 
stomachs  were  resected  between  1891  and  1901  for  carcinoma,  not  one 
is  alive  now;  whereas  of  the  four  patients  whose  stomachs  were  re- 
sected in  the  same  time  for  supposedly  benign  disease,  which  was  after- 
ward however  found  by  the  microscope  to  be  malignant,  but  in  an 
early  stage — that  of  these  four  patients,  the  first  is  well  eight  years  after 
the  operation,  the  second  is  well  four  years  after  the  operation,  the 
third  is  still  too  recent  to  count ;  and  only  one  died  of  recurrence,  and 
then  only  after  two  circular  resections  of  the  stomach.  For  single 
ulcers  he  advocates  partial  excision,  and  has  employed  in  two  cases 
elabourate  plastic  procedures  on  the  stomach,  the  operations  lasting 
one  and  one-quarter,  and  two  and   one-quarter  hours  respectively; 


ii8       Benign  Diseases  of  the  Stomach  and  Duodenum. 

both  patients  recovered.  For  more  extensive  disease  a  pylorectomy 
or  a  cvhndrical  resection  of  the  body  of  the  stomach  may  be  required. 
Jedhcka  further  quotes  Ssapesko  as  having  recorded  several  cases  in 
which  cancer  developed  in  ulcers  which  had  been  treated  by  gastro- 
enterostomy five  or  six  years  previously;  and  Jedlicka  argues  from 
this  that  these  deaths  should  be  charged  to  the  operation  of  gastro- 
enterostomy. Rodman  has  collected  130  cases  of  pylorectomy  for 
ulcer,  with  a  mortality  of  6.9  per  cent.  Brechot  collected  (1906)  32 
cases  of  pvlorectomy  for  benign  disease,  by  various  French  surgeons, 
with  3  deaths,  a  mortality  of  9.4  per  cent.  He  is  an  earnest  advocate 
of  gastrectomy  for  benign  disease,  and  because  this  teaching  seems  to 
us  pernicious,  we  have  been  at  some  pains  to  examine  his  paper,  and 
beg  to  call  attention  to  some  of  its  contents.  Brechot  insists  in  the 
first  place  on  the  importance  of  the  normal  physiology  of  the  duo- 
denum; we  grant  its  importance.  He  then  asserts  that  exclusion  of 
the  duodenum  as  effected  by  gastro-jejunostomy  materially  impairs 
the  digestive  functions;  this  we  deny,  and  as  he  brings  forward  no 
facts  of  value  sufficient  to  support  his  assertion,  it  is  perhaps  un- 
necessary to  call  attention  again  to  well  known  observations  (Steudel, 
Carle  and  Fantino,  Kausch,  Hartmann,  Soupault,  Mintz,  Katzen- 
stein,  etc.)  which  prove  the  contrary.  Brechot  divides  organic 
stenosis  into:  (i)  Those  forms  caused  by  kinking,  by  pylorospasm 
without  obvious  cause,  and  by  fibrous  stricture;  and  (2)  those  forms 
caused  by  benign  tumors,  or  ulceration  and  its  products.  For  the 
first  class  he  says  the  proper  operation  is  restoration  of  the  gastro- 
intestinal canal;  we  agree  with  him.  For  the  second  he  asserts  ex- 
cision should  be  done;  in  the  case  of  Ijcnign  tumors  we  think  lie  is 
right,  for  modern  experience  goes  to  show  that  few  such  tumors  arc 
clinically  really  benign;  Init  in  the  case  of  stenosis  from  ulceration  we 
still  think  that  gastro-jcjunoslomy  is  to  be  preferred  in  all  but  excep- 
tional cases.  After  again  stating  the  dangers  of  persistent  hemorrhage 
and  sub.sequent  perforation  after  gastro-jejunostomy,  he  urges  the 
danger  of  carcinomatous  implantation.  Jn  regard  to  hemorrhage 
and  perforation,  it  may  be  said  that  the  cast's  which  have  been  ob- 
served are  too  few  in  pro])ortion  to  the  total  number  of  o])erations 
performed  to  make  these  late  results  worthy  of  such  serious  con- 


Operations  for  Gastric  Ulcer.  119 

sideration;  and  in  regard  to  carcinoma,  it  may  justly  be  urged  that 
gastro-enterostomy  does  cure  the  ulcer,  and  thus  prevents  the  develope- 
ment  of  carcinoma.  After  rehearsing  all  the  failures  after  gastro- 
enterostomy, such  as  the  vicious  circle,  internal  hernia,  volvulus,  and 
peptic  ulcer  of  the  jejunum  (all  of  w^hich  are  now  things  of  the  past), 
Brechot  closes  his  essay  with  some  statistics  and  case  histories,  which 
he  claims  are  the  justification  of  his  conclusions.  As  recent  statistics, 
he  refers  to  62  gastro-enterostomies  by  von  Eiselsberg  (reported  by 
Clairmont)  with  ten  deaths,  a  mortality  of  16. i  per  cent.;  and  op- 
poses to  these  lugubrious  figures  a  record  of  eight  pylorectomies  by  the 
same  surgeon,  with  two  deaths;  but  when  he  perceives  that  the  latter 
mortality  is  25  per  cent.,  he  hastily  states  that  the  figures  involved  are 
too  small  to  be  significant.  Then  he  tabulates  thirty-one  case  his- 
tories, in  which  operations  are  recorded,  there  being  four  immediate 
and  two  remote  deaths  (13  per  cent,  mortality  at  least);  and  among 
the  twenty-five  who  recovered  from  pylorectomy,  only  four  are  re- 
ported as  permanently  cured,  and  in  most  of  these  no  date  is  given  as 
to  the  duration  of  the  post-operative  history.  Seventeen  patients  were 
not  traced  at  all,  and  four  were  not  cured  by  the  operations  employed. 
These  case  histories,  says  Brechot,  prove  "the  necessity  of  resection  of 
the  ulcer,  and  the  simultaneous  restoration  of  the  gastro-intestinal 
canal."  Let  any  candid  reader  compare  these  records  of  pylorectomy 
for  benign  disease  with  those  of  gastro-enterostomy  for  the  same  con- 
dition. Yet  to  assure  our  own  sincerity,  we  are  careful  to  note  that 
Mayo  Robson  has  recently  reported  the  occurrence  of  gastric  car- 
cinoma in  four  patients  among  97  treated  by  him  by  gastro-enterostomy 
at  periods  of  from  one  to  three  and  a  half  years  after  the  palliative 
operation;  and  Czerny  in  1902  found  that  3  out  of  53  such  patients 
subsequently  developed  gastric  carcinoma.  Among  the  64  patients 
of  Deaver,  traced  by  Whiting,  it  is  probable,  as,  already  mentioned, 
that  2  died  subsequently  of  carcinoma,  at  intervals  of  four  and  two 
years  respectively  after  operation.  But  on  the  other  hand  it  must  not 
be  forgotten  that  if  these  patients  had  been  treated  primarily  by  the 
more  dangerous  method  of  gastrectomy,  it  might  have  been  their  fate 
to  have  immediately  succumbed  to  the  operation — -a  result  immeasur- 
ably worse  than  the  remote  chance  of  carcinomatous  change  several 


120       Benign  Diseases  of  the  Stomach  and  Duodenum. 

years  subsequent  to  operation.  So  that  while  we  admit  in  the  ab- 
stract the  force  of  some  of  the  arguments  advanced  by  the  advocates  of 
excision,  it  seems  a  saner  course  to  hmit  the  more  dangerous  operation 
to  the  more  serious  condition  of  acknowledged  malignancy ;  and  when 
there  is  doubt  as  to  the  existence  of  malignant  disease,  to  perform  the 
more  extensive  operation  only  in  carefully  selected  cases.  Those 
gastric  ulcers  which  we  think  least  unsuited  for  treatment  by  excision 
are  those  encountered  at  some  distance  from  the  pylorus.  It  has  been 
observed  by  Moynihan  that  in  such  cases  gastro- enterostomy  is  useless 
or  actually  harmful;  and  he  very  positively  expresses  (1908)  his 
preference  for  excision  of  ulcers  "on  the  lesser  curvature  toward  the 
cardia."  Yet  we  cannot  entirely  accept  his  condemnation  of  gastro- 
jejunostomy for  ulcers  elsewhere  than  in  the  pyloric  region  of  the 
stomach.  The  patient  may  not  be  so  markedly  benefitted  as  in  the 
presence  of  pyloric  ulcer;  but  considerable  improvement,  if  not  im- 
mediately at  least  ultimately,  we  think  is  to  be  anticipated. 

In  stomachs  extensively  contracted  from  chronic  ulceration  Eiscls- 
berg  advises  the  palliative  operation  of  jejunostomy.  Duodenos- 
tomy,  above  the  bile  papilla,  has  been  urged  by  Hartmann  as  a 
better  operation.  His  own  operation  was  the  fourth  on  record  and  his 
patient,  who  had  extensive  burns  of  the  stomach,  survived  7  weeks. 
Bullitt  has  quite  recently  adopted  this  operation  in  a  patient  whose 
stomach  was  practically  obliterated  by  ulceration.  The  patient's  con- 
condition  of  slow  starvation  was  arrested,  his  general  health  consider- 
ably improved,  and  he  was  in  fair  health  ten  months  after  the  operation. 

In  regard  to  the  treatment  of  hemorrhage,  probably  enough 
has  been  said  in  the  section  on  prognosis,  where  it  was  pointed  out 
that  surgical  intervention  is  most  successful  in  those  patients  where 
ojjeration  can  be  done  between  attacks  of  hccmatemesis;  and  that 
operations  done  with  any  idea  of  locating  and  ligating  the  l^leeding 
point,  in  cases  of  acute  hemorrhage,  fail  in  the  immense  majority 
of  instances  to  accomplish  the  desired  result.  Yet  Dieulafoy  urges 
operation  in  these  very  cases  "at  the  opportune  moment."  In  the 
sudden,  profuse  and  overwhelming  bleeding  sometimes  encountered, 
and  which  is  generally  the  first  and  at  times  the  only  symptom  of 
the  "cxulccratio  simplex"  known  Ijy  his  name  (sec  ])age  71),  he 
strongly  counsels  surgical  intervention  on  llie  lirst  recurrence  of  the 


Treatment  in  Gastric  Hemorrhage.  I2I 

bleeding.  The  first  patient  whom  he  saw  with  this  variety  of  hemor- 
rhage died  from  recurrence  of  the  profuse  hsematemesis  shortly  after 
coming  under  observation.  At  the  autopsy  the  seat  of  the  hemor- 
rhage was  found  in  a  small  arteriole  just  beneath  the  muscularis 
mucosas,  which  had  been  perforated  by  an  "exulceratio  simplex." 
In  his  second  patient  he  correctly  diagnosed  the  cause  of  the  hem- 
orrhage, and  on  its  recurrence  the  next  morning  induced  Cazin  to 
operate  in  the  hope  of  finding  and  ligating  the  bleeding  point.  The 
stomach  was  opened  and  by  everting  its  mucous  lining  through  the 
incision  like  a  glove  on  the  hand,  and  by  minutely  searching  among 
the  mucous  folds  and  rugae,  a  suspicious  looking  area  was  detected. 
The  manipulation  and  sponging  of  the  area  started  the  hemorrhage 
afresh,  and  the  arteriole  was  then  ligated,  the  patient  making  a  good 
recovery.  Robson  and  Moynihan  iloc.  cit.,  p.  177)  have  recorded  two 
similar  cases  in  which  several  bleeding  points  were  successfully  ligated. 
We  should  feel  extremely  loath  to  undertake  an  operation  in  cases 
such  as  these,  where  the  chance  of  discovering  the  seat  of  the  hemor- 
rhage is  so  exceptionally  slight,  and  w^here  medical  treatment  offers 
a  probability  of  cure  in  a  fair  proportion  of  cases. 

The  alarming  mortality  which  attends  operations  undertaken  for 
the  relief  of  acute  hemorrhage  may  be  seen  from  the  following 
figures,  quoted  from  Lieblein  and  Hilgenreiner :  Hartmann  re- 
ported a  mortality  of  63  per  cent.;  Savariaud,  66  per  cent.;  Rob- 
son  (42  cases),  64  per  cent.;  Quenu,  45  per  cent.;  Kaupe,  40  per 
cent,  (probably  mostly  chronic  recurrent  bleeding).  Munro  (1904) 
out  of  a  series  of  eight  patients  operated  on  for  acute  hemorrhage 
saved  only  one.  Moynihan's  mortality  among  27  operations  was 
nearly  26  per  cent.  Tuffier  says  that  with  medical  treatment  the 
mortality  from  acute  gastric  hemorrhage  is  only  1.7  per  cent.,  so 
that  even  if  some  cases  included  under  medical  treatmeut  were  so 
mild  as  never  to  have  been  considered  surgical,  and  even  if  we  ac- 
cept the  highest  mortality  under  medical  treatment,  that  of  11  per 
cent.,  given  by  Miiller,  yet  the  difference  in  the  mortality  between 
medical  and  surgical  treatment  is  too  great  for  surgical  treatment  to 
be  preferred  in  patients  with  acute  hemorrhage  save  in  the  most 
exceptional  cases. 

Nor  in  recurrent  hemorrhage,  when  the  operation  is  done  in  the 


122       Benign  Diseases  of  the  Stomach  and  Duodenum. 

interval,  should  the  surgeon  seek  to  ligate  or  excise  the  offending 
ulcer.  Gastro-enterostomy  is  sufficient.  Terrier,  Kocher,  Miku- 
licz, Mayo  Robson,  ]Mayo,  JNIoynihan,  Hartmann,  v.  Eiselsberg, 
Tufl&er,  the  Boston  surgeons,  indeed  all  the  operators  whose  opin- 
ions on  gastric  surgery  carry  most  weight  are  unanimous  in  the 
verdict  that  gastro-enterostomy  is  sufficient. 

The  treatment  of  perforation  of  a  gastric  ulcer,  is  unques- 
tionably operative.  Without  operation  death  will  be  the  natural 
consequence  in  99  per  cent,  of  cases.  With  operation  from  fifty 
to  sixty  per  cent,  of  patients  are  being  saved,  and  with  prompt 
operation  the  recovery  rate  is  much  greater,  some  series  of  statistics 
showing  a  mortality  as  low  as  ten  per  cent.  Suture  of  a  gastric 
perforation  was  first  done  by  Mikulicz  in  1889,  but  without  success. 
The  first  instance  of  recovery  after  suture  of  a  gastric  perforation 
was  recorded  in  1892  by  Kriege.  Finney  in  1900  collected  statis- 
tics of  268  gastric  perforations  treated  by  operation,  the  mortality 
being  48  per  cent.  F.  Brunner,  in  1903,  collected  387  operations 
with  186  deaths,  a  mortality  of  48  per  cent.  English  in  1903 
analyzed  42  operations  for  gastric  perforation  done  at  St.  George's 
Hospital;  of  these  20  died,  a  mortality  of  48  per  cent.  Gross  and 
Gross,  whose  monograph  (1904)  on  the  subject  forms  the  most 
complete  as  well  as  the  most  recent  study  of  gastric  perforation, 
collected  from  various  sources  the  reports  of  369  operations; 
among  these  there  were  187  deaths,  a  mortality  of  50.67  per  cent. 
Patcrson  in  1906  collected  112  consecutive  operations  for  this  con- 
dition from  two  London  Hospitals,  with  58  deaths,  a  mortality  of 
nearly  52  per  cent.  He  states  that  during  1904,  no  less  than  58 
operations  for  perforation  of  gastric  ulcers  were  done  in  London 
Ho.spitals,  with  28  deaths,  or  48  per  cent,  mortality.  Thus  it  is 
evident  that  in  the  usual  run  of  cases  it  is  at  present  impossible  to 
save  more  than  half.  If  all  were  operated  on  at  the  most  opportune 
time,  that  is,  within  a  few  hours  of  perforation,  the  results  would  be 
much  better,  as  may  be  seen  in  the  accom])anying  table,  taken  from 
the  monograph  of  Gross  and  Gross  and  from  tliat  of  Brunner,  al- 
ready alluded  to.  In  237  instances  noted  by  Gross  and  Gross  the 
time  between  perforation  and  operation  was  recorded;  and  the 
results,  as  well  as  Brunncr's  figures,  may  be  thus  ])rcsented: 


Treatment  in  Gastric  Perforation.  123 

Mortality  Per  Cent. 
Duration  of  Perforation.  Gross  &  Gross.  Brunner. 

Less  than  12  hours 25.00  25.00 

Less  than  24  hours 52.72  46.00 

Less  than  48  hours 56.06  58.00 

More  than  48  hours 73-91  80.00 

If  the  results  of  individual  operators  are  examined,  it  will  be  seen 
also  that  the  personal  equation  has  something  to  do  with  the 
results.  Thus  a  surgeon  who  has  seen  a  number  of  these  patients 
will  not  only  make  his  diagnosis  more  quickly,  and  will  hence 
operate  sooner,  but  the  operation  itself  will  probably  be  performed 
with  greater  skill  and  despatch  than  will  one  done  by  the  occasional 
operator.  The  same  will  be  true  of  a  series  of  operations  done  in  a 
well-equipped  hospital,  by  various  members  of  the  same  staff; 
the  following  figures  accordingly  are  not  without  their  interest: 

RESULTS  OF  OPERATIONS  FOR  GASTRIC  PERFORATION. 

Mortality 
Operator.  Cases.  Rec.  Died.        Per  Cent. 

Anderson  (Lancet,  1904,  ii,  585) 7  4  3  42.8 

Bonheim   (Deutsch.    Zeit.    f.  '  Chir.,    1904, 

Ixxv,  389) 10  8  2  20.0 

Caird  (Scottish  Med.   &  Surg.  Jour.,  1906, 

ii,  215) 25  16  9  36.0 

Deaver  (Records  of  German  Hospital,  to 

June  I,  1908) 660  0.0* 

Eiselsberg    (Deutsch.    med.    Woch.,    1906, 

xxxii,  2017) _ 12  5  7  58.33 

Gibbon  (Trans.  Phila.  Acad.  Surg.,  1904, 

vi,  139;  Annals  of  Surg.,  1905,  i,  289) .        523  60.0 

Khautz  (Arch.  f.  klin.  Chir.    1908,  Ixxxv, 

700) II  3  8  72.72 

Jaffa  (Berl.  klin.  Woch.,  1908,  vlv,  346) 431  25.0 

Kirk  (Med.  Press  &  Circ,  1905,  i,  321) 10  9  i  lo.o 

Kummel    (cited   by   Eiselsberg:     Deutsch. 

med.  Woch.,  1906,  xxxii,  2017) 14  5  9  64.27 

Littlewood  (cited  by  Mayo  Robson,  Keen's 

Surgery,  Phila.,  1908,  Vol.  Ill,  p.  866)  .31  17  14  45.1 

Mitchell  (N.  Y.  Med.  Jour.,  1905,  ii,  417) . .      13  6  7  53.8 

Peck  (N.  Y.  Med.  Record,  1907,  ii  930)...        752  28.57 

Rehn   (cited   by   Noetzel:     Beitr.    z.    klin. 

Chir.,  1907,  Ii,  247) 16  9  7  43.75 

Smith  (Lancet,  1906;    cited  by  Eiselsberg: 

Deutsch.    med.    Woch.,    1906,    xxxii, 

2017) II  5  6  54-54 

Sonnenburg  (cited  by  Federmann:  Deutsch 

Zeit.  f.  Chir.,  1907,  Ixxxvii,  443)....      11  4  7  63.63 

Stewart  (Trans.  Phila.  Acad.  Surg.,  1907, 

ix,  176) 7  5  2  28.57 

White  (Brit.  Med.  Jour.,  1904,  i,  421) 5  3  2  40.0 

*  One  patient  was  operated  on  by  A.  D.  Whiting. 


124       Benign  Diseases  of  the  Stomach  and  Duodenum. 

Gross  and  Gross  also  analyzed  the  results  in  the  series  of  cases 
collected  by  them,  so  as  to  include  operations  done  within  five 
hours  after  perforation.  Thus  they  found  that  of  those  patients 
operated  on 

Within  the  first       five  hours 31 -03  per  cent.  died. 

"  "    second     "        "     16.25     "       "         " 

"  "    third        "        "     42.85     "       "         " 

"         "    fourth     "        "     54.00    "       "         " 

"    fifth         "        "     57.14    "       " 

This  seems  to  show  that  operations  undertaken  within  the  first  five 
hours  are  less  successful  than  those  done  during  the  second  period 
of  five  hours;  but  we  think  that  notwithstanding  these  figures  no 
surgeon  should  hesitate  to  open  the  abdomen  at  the  earliest  pos- 
sible moment  after  perforation  has  occurred.  To  wait  for  the 
shock  to  pass  is  usually  to  await  the  developement  of  an  irremedi- 
able peritonitis;  indeed  some  patients  are  so  profoundly  shocked 
that  they  do  not  survive  long  enough  for  peritoneal  reaction  to 
occur.  The  apparent  contradiction  between  clinical  experience 
and  the  figures  obtained  on  analysis  could  probably  in  this  instance 
as  in  others  be  satisfactorily  explained  if  the  cases  had  been  reported 
in  greater  detail;  when  it  probably  would  have  been  found  that  the 
majority  of  those  patients  operated  on  within  the  first  five  hours 
after  perforation,  suffered  from  severer  lesions  than  did  the  others. 
Shock  in  these  patients,  as  has  already  been  pointed  out,  is  in 
large  measure  due  to  the  presence  of  air  in  the  peritoneal  cavity; 
several  surgeons,  moreover,  have  noted  that  opening  of  the  peri- 
toneum and  allowing  the  escape  of  the  gas,  has  materially  lessened 
the  shock.  So  that  a  reasonable  hope  of  immediately  lessening  the 
shock  by  prompt  operation  may  be  entertained.  Thus  Mitchell 
says  that  in  one  of  his  patients  the  pulse  was  140  until  the  perito- 
neum was  opened  and  the  gas  allowed  to  escape,  when  it  fell  at  once 
to  96  and  became  fairly  strong  and  regular.  In  a  second  case  the 
escape  of  gas  on  opening  the  peritoneum  was  accomjoanicd  by  a 
fall  of  the  i)ulse  rate  from  108  to  88,  whik'  tlic  strength  of  the  ])ulse 
was  distinctly  imy)r()vcd.  On  the  oilier  liand,  there  was  very  little 
gaseous  distention  in  another  case,  and  in  this  patient  opening  the 
peritoneum  had  no  apj^reciable  effect  on  llie  pulse.     Other  surgeons 


Treatment  in  Gastric  Perforation.  125 

have  even  suggested  aspiration  of  the  intraperitoneal  gas  as  an 
euthanasial  measure,  in  cases  not  admitting  of  operation. 

Bearing  on  this  subject  the  observations  of  F.  Brunner  {loc. 
cit.,  S.  190)  are  of  interest.  He  constructed  curves  to  represent 
graphically  the  prognosis  after  operation  in  cases  of  gastric  perfora- 
tion. According  to  this  method  he  finds  that  the  curve  of  mor- 
tality gradually  approaches  that  of  recovery  up  to  the  eleventh  hour 
after  perforation,  when  it  crosses  the  curve  of  recovery,  and  there- 
after exceeds  it.  The  curve  of  recovery  before  the  eleventh  hour 
is  parallel  with  the  curve  of  abdominal  rigidity;  while  the  curve  of 
mortahty  after  the  eleventh  hour  is  parallel  to  the  curve  of  ab- 
dominal distention.  In  other  words,  at  the  eleventh  hour,  the 
chances  of  recovery  are  about  50  per  cent.,  being  greater  before, 
and  growing  progressively  less  after  the  fateful  hour  has  been 
passed.  The  prognosis  also  is  good  so  long  as  the  abdomen  is 
rigid;  but  when  absorption  of  peritonitic  toxines  has  caused  ab- 
dominal distention,  the  prognosis  becomes  progressively  worse  the 
longer  the  time  that  has  elapsed  since  the  subsidence  of  rigidity. 
All  these  observations  render  the  importance  of  prompt  operation 
so  much  the  more  apparent. 

Most  gastric  perforations  are  on  the  anterior  wall  of  the  stomach 
and  are  fairly  accessible.  Excision  of  the  ulcer  is  an  unnecessary 
waste  of  time;  by  this  procedure,  moreover,  the  surgeon  not  only 
leaves  himself  a  larger  opening  to  close,  but  may  also  add  the  com- 
plication of  hemorrhage  to  that  of  perforation,  since  some  good 
sized  vessels  may  be  unwittingly  divided.  Sero-serous  suture  of 
the  perforation,  without  even  attempting  to  freshen  its  edges,  is 
quite  sufficient. 

But  in  certain  instances  it  is  impossible  to  close  the  opening 
securely  by  suture,  and  in  some  rare  cases  the  perforation  will  be  so 
situated,  or  its  edges  will  be  so  friable  that  sutures  of  any  kind, 
even  insecure  sutures,  cannot  be  inserted.  Under  such  circum- 
stances the  surgeon  should  endeavour  to  close  the  perforation  by 
suturing  a  tag  of  the  great  omentum  over  it,  a  method  which  ap- 
pears to  have  been  first  employed  in  1897  by  Braun.  Or  the  gastro- 
hepatic  omentum  may  be  anchored  down  to  the  perforation  if  more 


126       Benign  Diseases  of  the  Stomach  and  Duodenum. 

con\-enient.  In  cases  where  such  devices  fail,  the  surgeon  should 
not  despair  of  curing  his  patient,  but  should  pack  off  the  per- 
forated area  with  gauze  pads,  as  is  done  in  similar  circumstances 
in  other  regions  of  the  abdomen.  This  is  a  much  safer  plan  than 
attempting  to  suture  the  perforation  to  the  abdominal  wall;  indeed 
were  figures  alone  to  be  our  guide,  gauze  packs  should  be  preferred 
even  to  suture  of  the  perforation.  F.  Brunner  (loc.  cit.,  S.  170) 
collected  15  cases  of  perforation  of  the  stomach  treated  by  packing 
without  suture.  Of  these  no  less  than  12  recovered;  whereas 
suture  of  the  perforation  to  the  abdominal  wall  is  nearly  always 
followed  by  death.  To  these  cases  of  gastric  perforation  treated 
by  packing,  recorded  by  Brunner,  may  be  added  Wood's  patient 
who  also  recovered,  thus  giving  16  recoveries  and  only  3  deaths  for 
this  method  of  treatment,  a  mortality  of  only  18.75  P^^  cent. 
The  resulting  gastric  fistula  has  closed  spontaneously  almost  without 
exception. 

Villard  and  Pinatelle  {loc.  cit.,  p.  856)  strongly  commend  pack- 
ing for  ulcers  which  have  perforated  among  adhesions  close  to  the 
lesser  curvature.  After  the  packs  have  been  placed  the  greater 
curvature  of  the  stomach  may  be  sutured  to  the  abdominal  wall 
if  there  is  doubt  as  to  the  efficiency  of  the  packs.  These  authors 
have  collected  9  cases  of  this  character,  treated  by  packing  without 
suture :  all  three  patients  in  whom  the  perforation  was  drained  by  a 
tube  into  the  stomach,  packed  around  with  gauze,  recovered  from 
the  operation;  while  of  the  remaining  six  patients  in  whom  gauze 
packs  alone  were  used,  four  recovered  and  two  died.  The  two 
fatal  cases  were  in  patients  operated  on  respectively  37  and  60 
hours  after  perforation  had  occurred;  the  first  survived  the  o])cra- 
tion  by  six  and  the  second  by  ten  days,  showing  that  they  possessed 
an  unusually  good  chance  of  ultimate  recovery. 

The  abdomen  should  almost  invariably  be  drained.  The 
surgeon  should  studiously  avoid  the  cxam])lc  of  Young  who,  be- 
cause he  thouf^ht  it  im])Ossible  to  chain  well,  (h'd  n(~)t  chain  at  all. 
The  unfortunate  ])atient  did  well  for  four  weeks  in  spile  of  the  fact 
that  he  had  two  ])erf{)rations  in  his  stomach;  but  finally  succumljcd 
in  the  fifth  week  to  exhaustion  due  to  a  large  subj)hrenic  abscess. 


Treatment  in  Gastric  Perforation.  127 

Should  a  second  perforation  be  looked  for?  Undoubtedly  it 
should ;  but  if  not  readily  found  further  time  should  not  be  wasted 
in  a  search  which  will  prove  futile  in  four  out  of  five  cases  at  the 
least,  especially  since  the  time  so  consumed  may  be  more  profit- 
ably spent,  we  believe,  in  the  performance  of  gastro-jejunostomy,  in 
selected  cases. 

Gastro-enterostomy  as  a  primary  operation  in  a  patient  with 
gastric  perforation  appears  to  have  been  first  employed  by  Braun 
in  1897  when  he  unexpectedly  found  a  perforation  in  a  patient  upon 
whom  he  was  preparing  to  do  a  gastro-enterostomy  for  pyloric 
stenosis.  Our  own  opinion  is  decidedly  in  favour  of  gastro- 
enterostomy. It  is  not  likely  that  in  cases  of  perforation  it  will  be 
found  expedient  to  combine  a  pyloroplasty  with  excision  of  the 
ulcer;  and  gastro-jejunostomy,  which  is  the  form  of  anastomosis  to 
be  preferred,  requires  so  little  additional  time  for  its  performance 
in  the  hands  of  those  who  are  habituated  to  abdominal  surgery, 
that  the  fact  that  it  prolongs  the  operation  cannot  justly  be  urged 
as  an  objection.  The  reason  for  performing  gastro-jejunostomy 
as  a  primary  operation,  is  two-fold :  first  to  promote  healing  of  the 
perforated  area,  and  second  to  prevent  recurrence  of  symptoms  or 
a  subsequent  perforation.  Yet  Villard  and  Pinatelle  think  gastro- 
enterostomy a  useless  complication,  and  English  is  opposed  to  it. 
The  last-named  author  traced  17  out  of  24  patients  who  recovered 
after  suture  of  a  gastric  perforation,  no  gastro-enterostomy  having 
been  done  in  any  case.  Of  these  17  patients,  13  had  no  further 
gastric  symptoms  (2  of  these  having  married  and  borne  children), 
and  4  were  dyspeptic,  presenting  symptoms  not  of  acute  ulcer,  but 
of  a  cicatrix  and  adhesions.  Yet  the  other  side  of  the  question  may 
be  supported  by  even  more  convincing  facts :  Paterson  states  that 
among  the  cases  of  gastric  perforation  Avhich  he  collected,  no  less 
than  13  deaths  out  of  a  total  of  58  could  almost  certainly  have  been 
prevented  if  a  primary  gastro-enterostomy  had  been  done;  so  that 
were  these  patients  transferred  to  the  recovery  column,  the  death 
rate  would  have  been  reduced  from  nearly  52  per  cent,  to  40 
per  cent.  Indeed  Paterson  goes  further  than  we  should  be  in- 
clined to  do,  and  claims  that  even  purulent  peritonitis  is  no  contra- 


128       Benign  Diseases  of  the  Stomach  and  Duodenum. 

indication  to  gastro-enterostomy.  Bonheim  succeeded  in  tracing 
only  two  patients.  They  had  not  been  treated  by  a  primary 
gastro-enterostomy;  one  had  a  subphrenic  abscess,  and  finally  re- 
covered after  another  operation;  while  the  other  suffered  from  a 
recurrence  of  symptoms  of  gastric  ulceration.  In  not  a  few  in- 
stances patients  who  have  been  operated  on  for  gastric  perforation 
and  have  not  had  a  gastro-enterostomy  done  primarily,  have  been 
forced  to  submit  to  this  operation  as  a  secondary  procedure  to 
secure  relief  from  their  gastric  symptoms.  AUingham  and  Thorpe 
had  to  do  gastro-enterostomy  one  month  later  to  accelerate  their 
patient's  convalescence;  Scudder  resorted  to  it  five  weeks  after, 
and  Gibbon  eighteen  months  after  suture  of  the  gastric  perforation. 
Mayo  and  Moynihan  have  had  a  similar  experience. 

It  has  been  possible  to  collect  from  the  recent  literature  only 
2  2  instances  in  which  gastro-enterostomy  was  employed  as  a 
primary  operation.  Of  these  patients,  17  recovered  (Anderson,  i; 
Caird,  i;  Clayton-Green,  i;  Jones,  2;  Lund,  3;  Lusk,  i;  Mayo, 
3;  Moynihan,  5)  and  only  5  died  (Caird,  i;  D.  F.  Jones,  i;  Mayo, 
2;  Moynihan,  i),  the  death  in  Jones's  patient  not  occurring  until 
the  third  week,  and  being  attributed  to  perforation  by  the  Murphy 
button  with  which  the  gastro-intestinal  anastomosis  was  made. 
To  these  cases  collected  from  the  literature,  may  be  added  live 
cases  operated  on  at  the  German  Hospital  by  Dcaver,  gastro- 
jejunostomy being  employed  as  a  primary  operation  in  every  case, 
and  all  of  the  patients  recovering.  It  is  thus,  we  think,  evident, 
that  in  any  case  where  it  is  not  specifically  and  positively  contra- 
indicated,  gastro-jejunostomy  should  be  employed  as  a  primary 
operation  in  patients  with  gastric  perforation.  Especially  important 
is  a  primary  gastro-jejunostomy  if  the  perforation  is  close  to  the 
pylorus,  for  it  will  then  be  very  likely  to  cause  obstruction  when 
cicatrization  has  been  completed.  Perforations  near  the  lesser  cur- 
vature, as  noted  by  Moynihan,  do  not  so  urgently  call  for  gastro- 
enterostomy. 

Exploratory  Laparotomy.  Operations  undertaken  in  ])a- 
tients  susjK'Ctcd  of  having  sutlcrcd  perforation  of  a  gastric  ulcer, 
must   in  the  nature  of  things  at  times  be  merely  explorations.     A 


Exploratory  Laparotomy.  129 

positive  diagnosis  is  not  always  possible,  and  it  is  usually  more  to 
the  patient's  interest  for  the  surgeon  with  proper  technique  at  his 
disposal,  to  explore  the  abdomen,  than  for  an  operation  to  be 
postponed  until  the  advent  of  unmistakable  peritonitis  renders  the 
diagnosis  certain.  Gross  and  Gross,  in  their  extensive  review  of 
the  literature  found  records  of  only  two  patients  who  died  after 
being  subjected  to  a  laparotomie  blanche,  as  it  has  been  called — that 
is  to  say  a  laparotomy  in  which  no  lesions  were  found  to  account 
for  the  symptoms.  Nor  could  these  two  solitary  deaths  be  attri- 
buted to  the  exploratory  operation,  since  death  in  one  was  due  to 
persistent  hsematemesis,  for  which  no  cause  could  be  found,  and 
in  the  other  was  caused  by  the  rupture  of  an  aortic  aneurism. 
Laparotomie  blanche  has  been  reported  by  Kirk  (3  cases),  by 
English  (3  cases),  and  by  Korte  (2  cases).  English  also  mentions 
4  other  patients  in  whom  operations  were  undertaken  for  gastric 
perforation,  but  in  whom  the  symptoms  were  found  to  have  another 
cause. 

(Esophageal  perforations  into  the  peritoneal  cavity  have  been 
recorded  by  Korte,  as  well  as  by  Mesnard  and  Feroualle.  Both 
patients  died. 

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9 


130       Benign  Diseases  of  the  Stomach  and  Duodenum. 

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Lusk:   Jour.  Amer.  Med.  Assoc,  1908,  i,  1553. 


Gastric  Ulcer.  131 

Mackenzie:   Cited  by  Bidwell,  Amer.  Jour.  Med.  Sc,  1899,  ii,  257. 

Maydl:   Quoted  by  Jedlicka,loc.  cit. 

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New  York,  1904,  p.  175. 
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Soupault:  See  Hartmann. 


132        Benign  Diseases  of  the  Stomach  and  Duodenum. 

Strassman:    Vierteljahrsschr.   f.   gerichtl.   Med.,    1907,   xxxiii,    SuppL,  S. 

143- 
Taylor,  W.  J.:   Trans.  Coll.  Phys.  Phila.,  1906,  xxviii,  17. 

Terrier:   Bull,  et  Mem.  Soc.  Chir.   Paris,  16  mai,  1904. 

Tuffier:   Chirurgie  de  I'Estomac,  Paris,  1907. 

Van  Valzah  and   Nisbet:    Diseases   of  the   Stomach,   London,    1900,    p. 

446;  et  passim. 
Villard  and  Pinatelle:    Revue  de  Chir.,  1904,  xxix,  708,  846;   xxx,  132. 
Wallis:   Brit.  Med.  Jour.,  1906,  i,  73. 

Welch:   Pepper's  System  of  Medicine,  Philadelphia,  1885,  ii,  485. 
^\^lite,  Hale:   Lancet,  1906,  ii,  1437. 
Wood:   Lancet,  1904,  ii,  1563. 
Young:   Scottish  Med.  and  Surg.  Jour.,  1905,  xvi,  510. 


CHAPTER  V . 

BENIGN  DISEASES    OF  THE   STOMACH    AND    DUODENUM 

(Continued). 

PYLORIC  OBSTRUCTION. 

Under  the  general  heading  of  pyloric  obstruction  it  is  convenient 
to  group  three  distinct  affections.  These  are  Infantile  Pyloric 
Stenosis,  Pylorospasm,  and  Gastric  Dilatation.  Although  pyloro- 
spasm  may  possibly  be  considered  merely  a  symptom,  and  gastric 
dilatation  a  complication  or  a  consequence  of  gastric  ulcer,  yet 
each  of  them  seems  of  sufficient  importance  to  render  its  inclusion 
within  the  present  section  not  only  logically  but  also  clinically  ad- 
visable. 

Infantile  Stenosis  of  the  Pylorus. 

Congenital  Hypertrophy  of  the  Pylorus,  or  Hyperemesis  Lactan- 
tium,  as  it  has  been  variously  called,  is  not  yet  a  distinct  pathological 
entity.  As  early  as  1788,  Beardsley  of  New  Haven  is  said,  on  the 
authority  of  Osier,  to  have  recognized  this  disease  clinically,  and 
to  have  described  his  findings  at  autopsy,  under  the  name  of  scirrhus 
of  the  pylorus.  Surgical  treatment  was  first  proposed  in  1896  by 
Schwyzer  who  suggested  Loreta's  operation;  and  was  first  employed 
in  1897  by  Stern  who  operated  by  gastro-enterostomy.  The  first 
successful  operation,  also  by  gastro-enterostomy,  was  performed  in 
1898  by  Lobker.  Further  references  to  the  literature  may  be  found 
in  the  articles  of  Neurath,  Trantenroth,  Cautley  and  Dent,  and 
Wachenheim. 

Because  surgeons  are  not  yet  in  accord  as  to  the  pathological 
changes  producing  the  symptomatology,  some  authors,  notably 
Meinhard   Schmidt,   have  preferred  to  retain  the  original  sympto- 

133 


134       Benign  Diseases  of  the  Stomach  and  Duodenum. 

matic  name  Hyperemesis  Lactantium.  But  the  trend  of  modern 
opinion  is  toward  the  adoption  of  the  term  Infantile  Stenosis,  which 
while  not  asserting  that  the  condition  is  a  congenital  deformity,  as 
some  have  maintained,  nor  committing  the  writer  to  any  clearly 
defined  pathology,  nevertheless  expresses  with  sufficient  accuracy 
the  changes  usually  found  at  operation  or  necropsy. 

etiology. — Three  theories  have  been  recognized  as  to  the 
causation  of  the  symptoms  about  to  be  described.  These  may 
be  briefly  denominated  the  congenital  abnormality  theory,  the 
hypertrophy  theory,  and  the  theory  of  simple  spasm.  The  first 
asserts  that  the  pyloric  stenosis  is  a  congenital  abnormality  quite 
as  truly  as  hare-lip,  webbed  fingers,  or  imperf oration  of  the  anus. 
Cautley  and  Dent  state  that  the  pyloric  thickening  is  primary, 
and  due  simply  to  a  redundance  of  tissue,  placed  there  by  nature 
as  the  result  of  over-exertion  in  forming  the  ordinary  sphincter. 
In  support  of  this  theory,  Neurath  asserted  that  a  family  predis- 
position might  exist,  quoting  Henschel  who  observed  three,  and 
Ashby  who  observed  four  cases  in  the  same  family.  Moreover, 
in  one  of  Ashby's  cases  there  was  also  atresia  ani,  a  fact  which 
Neurath  thinks  lends  support  to  the  congenital  abnormality  theory, 
not  to  that  of  spasm  nor  to  that  of  hypertrophy.  Actual  atresia 
of  the  pylorus  or  duodenum  has  in  a  few  instances  been  found 
at  autopsy  (Cleemann,  Eastes,  Goodhart,  Habheggar,  Lesshaft, 
etc.).  Should  it  by  any  possibility  be  recognized  during  life,  it 
would  of  course  be  susceptible  of  operative  relief,  even  if  with  very 
small  chance  of  success.  Maylard  has  called  attention  to  congen- 
ital narrowness  of  the  pylorus,  not  caused  by  hyperplasia  of  the 
pyloric  sphincter,  as  a  cause  of  indigestion  in  young  adults;  Mayo 
Robson  has  also  seen  it;  and  it  is  of  course  possible  that  some 
cases  of  hyjjeremcsis  lactantium  may  Ijc  due  to  a  simikir  condition. 
But  that  the  symptoms  of  this  malady  are  very  rarely  manifested 
before  the  baby  is  a  week  old  at  least,  and  that  in  several  instances 
children  no  longer  infants  have  developed  the  disease  (Sonnen- 
burg's  patient  was  six  years  of  age),  are  facts  wliicli  militate  strongly 
against  the  assum])tion  that  the  affection  is  due  to  any  deformity 
exi.sting  before  birth.     At  almost  every  autopsy  and  operation  at 


Infantile  Stenosis  of  the  Pylorus.  135 

which  the  pylorus  in  these  patients  has  been  brought  to  view,  the 
actual  condition  has  been  found  to  be  one  of  increase  in  the  muscu- 
lar tissue,  particularly  the  circular  muscle  fibres  surrounding  the 
pyloric  opening  of  the  stomach.  And  what  lends  further  support 
to  the  theory  that  it  is  an  hypertrophic,  not  a  neoplastic,  over- 
growth, is  the  fact  that  on  the  gastric  side  the  thickening  is  not 
sharply  limited,  but  extends  for  some  distance  into  the  pyloric 
portion  of  the  stomach,  as  an  hypertrophic  overgrowth  might 
be  expected  to  do,  since  the  pyloric  antrum  would  naturally  be 
involved  in  such  change;  whereas  on  the  duodenal  side  the  thick- 
ening ceases  suddenly,  and  within  a  ver}^  short  space  after  the  pylorus 
is  passed  the  duodenum  has  been  found  to  present  its  normal  charac- 
teristics. 

To  induce  this  hypertrophy  alleged  to  be  the  pathological  change, 
it  may  be  assumed  that  there  is  or  that  there  has  been  a  small 
erosion  or  fissure  in  the  pyloric  region  of  the  stomach,  and  that 
there  has  also  been  hyperacidity  of  the  gastric  juice.  That  these 
factors,  so  well  known  as  causes  of  pylorospasm  in  the  adult,  should 
in  the  infant  be  provocative  of  like  change,  appears  in  no  way  un- 
reasonable; and  if  it  be  objected  that  sufficient  time  does  not  elapse 
between  birth  and  the  occurrence  of  the  hypertrophy  for  it  to  be 
explained  on  these  grounds,  it  may  with  perfect  justice  be  replied 
that  infantile  tissues  cannot  always  be  judged  by  standards  derived 
from  adult  life.  John  Thomson,  the  well  known  paediatrist,  has 
supported  the  theory  of  hypertrophy  due  to  incoordination  of  the 
muscle  during  fcetal  life,  and  Jedlicka  also  maintains  that  prolonged 
spasm  may  induce  hypertrophy.  Meinhard  Schmidt  compares  the 
condition  to  that  of  vaginismus,  tenesmus  ani,  and  blepharospasm, 
which  are  frequently  caused  by  fissure  or  ulcer.  Yet  Rolleston 
reminds  us  that  no  hypertrophy  of  the  pylorus  is  found  in  Reich- 
mann's  disease,  gastro-succorhoea,  which  is  usually  accompanied  by 
pylorospasm.  But  as  has  been  said  before,  it  is  not  always  safe  to 
argue  from  adult  to  infantile  conditions.  Pfaundler,  while  not  deny- 
ing the  presence  in  some  of  these  patients  of  increase  of  muscular 
tissue,  considers  the  condition  in  most  instances  merely  one  of  spas- 
ticity.    But  as  Cautley  and  Dent  point  out,  the  cut  sphincter  does 


136       Benign  Diseases  of  the  Stomach  and  Duodenum. 


not  retract,  which  it  certainly  would  do,  were  the  condition  merely 
one  of  spastictity.  Heubner,  from  a  study  of  41  cases  encountered 
among  10,000  children,  concludes  that  the  affection  is  due  to  pyloro- 
spasm  causing  hypertrophy.  And  Pfaundler,  in  his  latest  utterance, 
recognizes  the  existence  of  two  forms — hypertrophic  and  spasmodic — 
the  latter  being  intermittent  in  character.  Our  own  tendency  is  to 
hold  that  the  unquestionable  increase  in  muscular  tissue  is  in  the 

nature  of  an  hypertrophy, 
and  is  brought  about  by 
persistent  spasm  due  to 
irritation  from  one  cause 
or  another. 

The  redundance  of 
mucous  membrane,  to  be 
presently  alluded  to,  may 
act  itself  so  as  to  provoke 
spasm,  much  as  a  polypus 
does  in  the  same  and  in  sim- 
ilar situations.  It  should, 
perhaps,  be  noted  that 
Wernstedt  has  tried  to  ex- 
plain the  presence  of  this 
mucous  fold  by  studies  in 
comparative  anatomy.  Ir- 
ritating diet  in  some  pa- 
tients, notably  in  Gard- 
ner's, has  been  almost  certainly  the  cause  of  spasm;  while  the  existence 
of  a  small  fissure  or  erosion  may  be  assumed  unless  the  contrary  can 
be  proved.  Hyperacidity,  at  first  very  probably  a  consequence  of 
the  stenosis,  may  soon  become  a  cause  of  its  continuance. 

It  is  to  be  hoped  that  further  study,  both  clinical  and  micro- 
scopical, will  elucidate  these  questions,  and  place  the  pathology  of 
this  serious  condition  on  a  firm  basis.  Until  then  we  must  be 
content  to  theorize  as  to  the  causes,  and  proceed  as  best  we  may, 
empirically,  to  adopt  uncertain  treatment  for  fairly  characteristic 
symjjtoms. 


Fig.  19. — Infantile  Stenosis  of  the  Pylorus. 

Natural  Size. 
Note   the    thickened   sphincter  and   the    fold    of 
mucous    membrane   occluding  the  orifice. 


Infantile  Stenosis  of  the  Pylorus.  137 

The  usual  appearance  of  the  parts  involved  is  very  well  shown 
in  Figure  19,  copied  from  Cautley  and  Dent's  article.  At  first 
glance  the  resemblance  to  an  enlarged  prostate  with  the  bladder 
attached,  is  quite  striking;  and  this  becomes  greater  when  on  more 
careful  examination  we  see  a  fold  of  mucous  membrane  which 
corresponds  very  closely  in  appearance  to  the  uvula  vesicae.  This 
mucous  fold  is  a  characteristic  feature  of  infantile  pyloric  stenosis, 
and  often  renders  nearly  complete  the  obliteration  of  the  passage 
from  the  stomach  to  the  duodenum,  even  when  the  mere  muscu- 
cular  mass  would  with  ease  permit  the  passage  of  a  probe  through 
the  pylorus.  Meinhard  Schmidt  estimates  the  calibre  of  the  normal 
pylorus  at  birth  as  admitting  a  No.  19  French  sound,  and  as  in- 
creasing one  number  of  the  French  scale  (or  one-third  of  a  milli- 
metre in  diameter)  for  each  month  of  life;  so  that  a  diameter  of 
nine  millimetres,  equal  to  No.  27  of  the  French  scale,  would  be 
normal  for  a  child  of  eight  or  nine  months  of  age,  and  at  twelve 
months  of  age  the  normal  pylorus  should  admit  a  No.  32  F.  Ac- 
cording to  Fisk,  Still  has  stated  that  at  six  months  of  age  the  normal 
pyloric  wall  is  about  2.5  mm.  thick;  while  in  hypertrophic  stenosis 
it  has  been  found  to  vary  from  3.5  to  5.7  mm.  in  thickness. 

In  only  a  few  instances  have  there  been  any  microscopical 
evidences,  even  slight,  of  acute  inflammation;  so  that  with  our 
present  knowledge  we  are  limited  to  the  theories  already  mentioned 
of  neoplastic  and  hypertrophic  overgrowth,  the  latter  seeming  the 
more  reasonable  of  the  two. 

Symptoms. —  The  symptoms  of  this  affection  do  not  differ 
materially  from  those  of  the  same  condition  in  adults.  The  chief 
subjective  signs  are  vomiting  and  constipation,  and  the  chief  objec- 
tive signs  are  a  pyloric  tumor  and  visible  gastric  peristalsis.  The 
vomiting  usually  does  not  begin  until  the  baby  is  about  a  week 
or  ten  days  old,  though  in  rare  instances  it  has  been  noted  from 
birth,  or  has  not  appeared  for  a  month  or  more.  In  the  earliest 
stages  liquids  may  be  rejected  almost  as  soon  as  they  are  swal- 
lowed. The  vomiting  is  nearly  invariably  cumulative,  when  the 
disease  has  lasted  more  than  a  few  weeks;   that  is  to  say,  three  or 


138       Benign  Diseases  of  the  Stomach  and  Duodenum. 

four  feedings  will  be  retained,  and  then  after  the  last  feeding  the 
whole  of  the  gastric  contents  will  be  rejected  at  once.  Hyper- 
acidity is  usually  present.  Bile  is  conspicuous  by  its  absence 
from  the  vomitus.  The  lack  of  absorption  is  accountable  for  the 
constant  hunger,  the  persistent  constipation,  and  the  progressive 
emaciation.  These  babies  should  be  weighed  at  regular  intervals. 
There  is  no  other  method  which  so  surely  shows  the  loss  of  flesh. 
As  emaciation  proceeds  and  the  vomiting  becomes  more  marked, 
as  it  usually  does,  there  is  as  a  rule  very  little  difficulty  in  detecting 
a  pyloric  tumor;  indeed  this  is  frequently  visible  to  the  most  casual 
glance,  projecting  from  the  sunken  and  withered  belly  in  a  char- 
acteristic manner.  Close  observation  will  now  usually  detect  peri- 
staltic waves  in  the  stomach,  commencing  in  the  left  hypochon- 
driac region,  passing  across  the  epigastrium,  and  culminating  in 
the  pyloric  tumor  which  sometimes  may  be  felt  to  become  denser 
on  contraction.  At  rare  intervals  a  peristaltic  wave  may  pass 
beyond  the  stenosed  pylorus,  and  diffuse  itself  through  the  small 
intestines,  but  as  a  rule  the  visible  contraction  ceases  at  the  pylorus. 
When  this  stage  is  well  advanced,  gastric  dilatation  commences, 
and  may  become  excessive.     It  is  recognized  by  the  usual  signs. 

Tetany,  evidently  of  gastric  origin,  was  a  marked  symptom  in 
a  case  operated  on  unsuccessfully  by  Munro. 

Prognosis. — It  is  difficult  to  reach  definite  conclusions  as  to 
the  prognosis  of  a  disease  about  the  pathology  of  which  so  little 
is  known.  If  we  follow  some  authors  in  placing  every  case  of 
rebellious  infantile  vomiting  in  this  category,  the  prognosis  will 
be  fairly  good,  since  the  largest  proportion  of  such  babies  soon 
recover  when  their  diet  is  regulated  in  quality  and  in  quantity.  If, 
on  the  other  hand,  we  claim  that  all  infants  who  recover  without 
operation  never  had  pyloric  stenosis,  or  assert  with  Cautley.  and 
Dent  that  unless  operated  on  all  these  patients  die  before  they  are 
four  months  of  age — then,  under  these  circumstances,  we  repeat, 
the  prognosis  must  be  considered  grave.  And  on  our  fundamental 
belief  as  to  the  gravity  of  the  prognosis  our  ideas  as  to  surgical 
treatment  must  be  based.     It  is  proljably  safe  to  assert  with  Melt- 


Infantile  Stenosis  of  the  Pylorus.  139 

zer  that  if  these  infants  survive  without  operation  more  than  four 
months  their  grade  of  stenosis  must  have  been  slight. 

Treatment. — It  is  needless  to  say  that  medical  treatment 
should  first  be  extensively  tried;  and  it  is  our  belief  that  in  the 
immense  majority  of  cases  medical  treatment  promptly  instituted 
and  energetically  applied  will  be  successful  in  curing  the  patient. 
If  the  views  as  to  the  pathology  of  the  affection  set  forth  in  these 
pages  be  correct,  that  the  thickening  is  not  neoplastic,  but  is  devel- 
oped as  the  result  of  irritation  of  some  kind  or  another,  then  there 
is  every  reason  to  think  that  medical  treatment  will  in  most  cases 
be  able  to  prevent  the  hypertrophic  overgrowth  of  muscle  tissue; 
and  in  a  few  cases  to  arrest  it  and  perhaps  to  cause  its  disappearance 
if  such  treatment  had  not  been  instituted  as  promptly  as  was 
desirable.  The  average  surgeon  is  too  apt  to  overlook  the  fact 
that  cures  have  resulted,  even  in  advanced  cases,  under  judicious 
medical  treatment.  Against  the  figures  of  Neurath,  who  collected 
41  cases  of  pyloric  stenosis  in  infants  less  than  twelve  months  old, 
all  of  whom  died  under  medical  treatment,  must  be  set  occasional 
case  reports  like  that  of  Gardner  and  those  of  Bloch,  in  the  latter 
of  which  there  are  recorded  twelve  cases  of  infantile  pyloric  stenosis, 
8  patients  recovering  without  operation,  2  dying  with  the  perform- 
ance of  Loreta's  operation,  and  2  being  moribund  when  admitted 
and  dying  soon  after,  without  operation. 

Where  medical  treatment  fails,  or  where  it  has  not  been  insti- 
tuted until  too  late  to  be  of  any  value,  then  surgery  is  available; 
and  the  one  practical  point  to  be  learned  from  a  study  of  statistics 
already  published,  is  that  the  earlier  an  operation  is  done,  when 
once  it  has  been  determined  upon,  the  greater  is  the  chance  of 
success.  Progressive  loss  of  weight  is  in  our  opinion  the  most 
imperative  indication  for  operation.  Unless  weight  is  being  lost 
it  is  almost  certain  that  a  sufficient  amount  of  food  is  being  absorbed 
to  sustain  life,  no  matter  how  constant  and  copious  the  vomiting 
may  seem  to  be.  According  to  Fisk's  figures,  the  average  age  at 
which  successful  gastro-jejunostomies  have  been  done  is  6.7  weeks; 
while  the  average  age  for  the  fatal  gastro-jejunostomies  is  8  weeks. 


140       Benign  Diseases  of  the  Stomach  and  Duodenum. 

When  surgical  intervention  has  been  decided  upon,  it  then  be- 
comes necessary  to  select  some  form  of  operation;  and  in  doing 
this  we  should  be  guided  not  only  by  the  change  in  the  stomach, 
but  also  by  the  tender  age  of  the  patient.  The  operations  employed 
have  been  pylorodiosis  (Nicoll,  AI.  Schmidt,  Stiles,  Burghard,  Gris- 
son,  Mackay,  Grunneberg,  Bloch),  pyloroplasty  (Braun,  Dent, 
Gillavrv,  Granborn,  Campbell,  Guthrie,  Morison),  and  gastro-jejun- 
ostomy  (Stern,  Me^^er,  Lobker,  Fritsche,  Abel,  Kehr,  Stiles,  Miku- 
licz, Nicoll,  Monnier,  Trantenroth,  Jordan,  Braun,  Schotten,  Mackay, 
Jakh,  Bull,  Pinner,  Munro,  Bottomley,  Giles,  Elting,  Scudder,  Ibra- 
him, Rogers,  Stone,  Roberston,  Murphy,  Abt,  Barling,  Kimball  and 
Hartley,  Bloch,  Cheney,  Bunts).  Pylorectomy  has  been  employed 
only  once,  by  Stiles,  with  fatal  result.  Sturmdorf  employed  gastro- 
pyloro-duodenostomy  unsuccessfully  in  one  case. 

Simple  pvlorodiosis  w^as  performed  by  Schmidt  with  steel  sounds 
passed  through  the  pylorus  by  means  of  an  incision  in  the  stomach. 
In  this  mann^  any  degree  of  dilatation,  corresponding  to  the  scale 
for  infants  already  given  (page  137),  may  be  obtained.  It  is  an 
operation  which  may  be  quickly  performed,  requires  very  little 
exposure  of  the  viscera,  and  is  therefore  theoretically  safe.  But 
in  not  a  few  instances  the  pylorus  has  split  instead  of  stretching, 
and  death  has  resulted  from  shock  or  peritonitis.  Dufour  and 
Fredet  have  collected  36  operations  by  this  method,  with  9  deaths, 
a  mortality  of  41.66  per  cent.;  and  since  one  of  the  patients  who 
recovered  required  gastro-enterostomy  three  weeks  later,  the  fig- 
ures are  not  really  so  good  as  they  seem.  Pyloroplasty  has  its  ad- 
vocates and  its  adversaries  for  this  condition,  as  for  otliers.  It 
is  asserted  that  the  thickness  of  the  ]:)ylorus  renders  the  oj)eration 
difficult  and  dangerous.  It  is  maintained,  on  the  other  hand,  that 
these  objections  are  merely  theoretical,  and  that  actual  experience 
with  the  operation  proves  it  easy  of  execution,  safe,  and  thoroughly 
efficient.  As  performed  by  Nicoll,  in  conjunction  with  divulsion, 
it  certainly  seems  to  l)car  out  these  statements.  Nicoll,  whose 
record,  we  belie\'e,  has  not  been  surpassed,  has  re])orted  sixteen 
ojjcrations  of  various  kinds  for  infantile  pxloric  stenosis,  with  only 


Infantile  Stenosis  of  the    Pylorus.  141 

four  deaths,  a  mortality  of  25  per  cent.  His  first  patient,  alive 
and  well  seven  years  after  the  operation,  was  operated  on  in  1899 
by  simple  divulsion;  and  the  six  latest  patients,  of  whom  only  one 
died  (from  shock)  were  operated  on  at  ages  varying  from  three 
weeks  to  ten  months  by  the  following  technique:  An  incision  is 
made  in  A  or  V-shape  down  to  the  mucosa  of  the  pylorus,  which 
is  not  opened.  The  pylorus  is  then  forcibly  divulsed  by  forceps 
introduced  through  a  separate  incision  in  the  anterior  wall  of  the 
stomach.  The  incision  in  the  pyloric  wall  is  then  closed  thus,  A 
or  Y.  Clamps  are  used  on  the  stomach  and  duodenum  to  prevent 
extravasation  of  their  contents.  No  recurrence  was  noted.  Fisk 
has  collected  in  all  1 1  operations  by  pyloroplasty,  with  5  deaths,  a 
mortality  of  45.46  per  cent.  But  as  two  of  these  deaths  did  not 
occur  until  five  weeks  and  ten  weeks  respectively  after  the  opera- 
tion, and  as  they  were  in  no  wise  caused  by  the  operation,  Fisk 
thinks  it  fair  to  count  them  as  recoveries,  which  would  give  8  re- 
coveries and  only  3  deaths,  or  a  mortality  of  27.28  per  cent.  But 
of  the  22  pyloroplasties  collected  by  Dufour  and  Fredet  9  ended 
fatally,  a  mortality  of  40.9  per  cent.  Gastro-jejunostomy,  the  most 
radical  operation  available,  has  been  employed,  according  to  Bunts, 
in  69  cases  with  37  deaths,  a  mortality  of  53.60  per  cent.  In  favour 
of  gastro-jejunostomy  the  most  that  can  be  said  is  that  if  it  does 
not  kill  it  will  cure.  No  recurrences  have  been  noted  in  patients 
who  have  survived.  But  it  does  seem  to  us  that  not  only  is  it  too 
dangerous  a  remedy  to  be  indiscriminately  applied  to  infants,  but 
that  it  is  inherently  wTong  to  start  children  off  on  what  it  is  hoped 
may  be  a  long  life,  with  their  gastro-intestinal  tract  so  distorted 
as  it  is  after  even  the  most  skillfully  executed  gastro-jejunostomy. 
It  appears  to  us  that  the  surgeon  who  has  occasion  to  operate  on 
patients  with  this  disease  should  aim  to  do  some  form  of  pyloro- 
plasty; and  that  only  when  such  a  procedure  is  found  on  opening  the 
abdomen  to  be  impracticable,  should  he  resort  to  gastro-jejunostomy. 
When  employed,  the  posterior  "no-loop"  operation  should  be 
adopted,  the  anastomosis  being  accomplished  by  suture  without 
mechanical  device. 


142       Benign  Diseases  of  the  Stomach  and  Duodenum. 

SUMMARY  OF  OPERATIONS   FOR  INFANTILE  STENOSIS  OF  THE 

PYLORUS. 

{After  Dufour  and  Fredet.) 

Mortality 

Operation.                              No.  of  Cases.          Rec.               Died.  Per  Cent. 

Explorator}'  laparotomy 2                   o                   2  100.00 

Jejunostomy i                     o                     i  100.00 

Pylorectomy i                    o                    i  100.00 

Pylorodiosis 36                 21                  15  41.66 

Pyloroplast)' 22                   13                    9  40.9 

NicoU's  operation 13                  11                    2  iS-S^ 

Gastro-jejunostomy  (Bunts) 69                 32                  37*  S3-6o 

Not  named 826  75.0 

152                  79                 73  48.02 


REFERENCES. 

Bloch:  Hospitalstidende,  Copenhagen,  1906,  xliv,  Nos.  5-7. 

Bloch:  Jahrb.  f.  Kinderheilk.,  1907,  Ixv,  No.  4. 

Bunts:  Annals  of  Surgery,  1908,  i,  946. 

Cautley  and  Dent:  Trans.  Med.-Chir.  Soc,  London,  1903,  Ixxxviii,  471. 

Cautley  and  Dent:   Brit.  Med.  Jour.,  1906,  ii,  939. 

Cheney:   Illinois  Med.  Jour.,  1907,  xi,  157. 

Dent:  See  Cautley,  Brit.  Med.  Jour.,  1906,  ii,  939. 

Dufour  and  Fredet:   Revue  de  Chir.,  1908,  xxxvii,  208. 

Fisk:  Annals  of  Surgery,  1906,  ii,  i. 

Gardner:   Lancet,  1903,  i,  100. 

Heubner:   Therapie  der  Gegenwart,  1906,  xlvii,  433. 

Jedlicka:    Operat.  Behandl.  d.  chron.  MagengeschwiJrs,  Prag,   1904,    S. 

18. 
Keefe:   Cited  by  Putnam,  Brit.  Med.  Jour.,  1906,  ii,  948. 
Lobker:  Verhandl.  d.  Deutsch.  Gesellsch.  f.  Chir.,  1900,  xxix,  148. 
Maylard:   Brit.  Med.  Jour.,  1904,  i,  416. 
Morison:   Lancet,  1904,  ii,  1782. 

Munro:  Cited  by  Townsend,  Bost.  Med.  and  Surg.  Jour.,  1904,  cl,  154. 
Neurath:   Centralbl.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1899,  ii,  696;   757. 
Nicoll:   Glasgow  Med.  Jour.,  1906,  Ixv,  253. 
Osier:  Bost.  Med.  and  Surg.  Jour.,  1903,  i,  278;  Archives  of  Pediatrics, 

/903,  ^^,  355- 
Pfaundler:  Virchow's  Archiv  f.  path.  Anat.,  1905,  clxxxi,  S.  199. 
Pfaundlcr  anfl  Schlossmann:    Handle,  d.   Kinderkrankh.,   Leipzig,    1906, 

Bd.  ii,  Halfte  i,  S.  181. 
RoJleston:  Trans.  Med.-Chir.  Soc,  London,  1903,  Ixxxviii,  511. 
Schmidt,  Meinhard:    Arch.  f.  klin.  Chir.,  1901,  Ixiii.  976. 
Schwyzer:   N.  Y.  med.  Monatschr.,  1896,  viii,  379. 
Stiles:   Brit.  Med.  Jour.,  1906,  ii,  943. 
Stern:  Deutsch.  med.  Woch.,  1898,  xxiv,  601. 
Sturmdorf:    Citcfl  by  iMschcr,  Archives  of  Pediatrics,  1906,  xxiii,  348. 


Pylorospasm.  143 

Thomson:   Brit.  Med.  Jour.,  1902,  ii,  678. 

Trantenroth:   Mitth.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1902,  ix,  724. 

Wachenheim:  Amer.  Jour.  Med.  Sc,  1905,  i,  636. 

Wernstedt:  Jahrb.  f.  Kinderheilk.,  1907,  Ixv,  674. 


Pylorospasm. 
This  is  an  intermittent  or  constant  contraction  of  the  pyloric 
sphincter,  attended  by  more  or  less  evident  symptoms.  Some 
physicians  recognize  both  a  primary  and  a  secondary  form;  thus 
Hemmeter  says:  "While  the  existence  of  a  secondary  cramp  of  the 
pylorus  is  generally  recognized,  strange  to  say  the  existence  of  a 
primary  cramp  of  the  pylorus,  caused  by  an  independent  motor 
neurosis,  restricted  to  the  pylorus  alone,  is  still  generally  denied. 
If  one  grants,  however,  that  the  insufficiency  of  the  pylorus  may 
appear  also  as  a  genuine  motor  neurosis,  due  to  a  decrease  of  the 
irritabihty  of  the  motor  nerve  apparatus  of  the  pylorus,  there  is  no 
reason  to  deny  entirely  the  occurrence  of  a  primary  cramp  of  the 
pylorus,  which  is  due  to  an  abnormally  increased  irritability  of  the 
motor  nerves',  even  though  this  be  rare."  No  one  can  dispute  the 
fact  that  surgery  can  only  legitimately  concern  itself  with  the  secondary 
form  of  pylorospasm — that  form  caused  by  some  definite  anatomical 
change.  But  as  the  surgeon  must  not  be  content  to  take  his  diagnosis 
ready  made  from  the  physician,  and  as  it  seems  to  us  that  Hem- 
meter's  premises  are  open  to  dispute,  no  matter  how  logical  his  con- 
clusions may  be,  it  appears  not  improper  to  question  in  this  place  the 
existence  of  a  primary,  purely  functional,  pylorospasm,  which  can  be 
productive  of  significant  symptoms.  We  hope  not  to  be  charged 
with  "beating  the  air,"  when  we  admit  on  the  one  hand,  the  abstract 
possibility  of  the  existence  of  a  primary  spasm  of  the  pylorus,  and 
when  we  deny,  on  the  other,  the  concrete  presence  of  any  form  of 
pylorospasm  not  produced  by  some  anatomical  change.  It  is  no 
more  unreasonable  to  deny  the  existence  of  primary  pylorospasm  than 
it  is  to  deny  that  of  idiopathic  peritonitis;  and  to  assert  that  every 
case  of  pylorospasm  for  which  no  gross  pathological  change  can 
be  found  must  be  purely  functional  in  origin,  appears  to  us  quite 
as  illogical  as  it  would  be  with  our  present  knowledge  of  the  path- 


144       Benign  Diseases  of  the  Stomach  and  Duodenum. 

ology  of  peritonitis  to  class  all  obscure  abdominal  inflammations  as 
idiopathic  peritonitis,  as  was  formerly  done.  It  is  our  firm  belief 
that  the  cases  of  so-called  primary  pylorospasm  are  due  to  the 
same  causes  as  those  operative  in  easily  recognized  cases  of  secon- 
dary cramp  of  the  pylorus,  though  in  the  former  class  of  cases  the 
causes  are  no  doubt  less  in  degree,  and  hence  are  more  readily 
reheved  by  medical  means.  We  may  even  go  further,  and  state 
that  we  have  never  seen  a  case  of  purely  functional  pylorospasm, 
and  that  none  of  our  medical  brethren  have  been  able  to  furnish 
even  one  patient  in  whom  they  were  confident  that  operation  or 
necropsy  would  reveal  no  anatomical  cause  for  the  spasm.  Wlien 
we  know  what  very  alarming  hemorrhage  may  come  from  a  minute 
erosion  in  the  stomach  scarcely  to  be  detected  by  the  most  pains- 
taking post-mortem  investigation,  surely  it  is  senseless  to  deny 
that  a  somewhat  similar  lesion,  not  perforating  a  blood  vessel,  may 
also  be  present  in  patients  with  pylorospasm,  and  may  heal  under 
medical  treatment  and  leave  no  trace  of  its  existence.  What  was 
said  in  support  of  the  theory  of  hypertrophy  from  spasm,  when 
speaking  of  the  causes  of  infantile  stenosis  of  the  pylorus,  should 
be  borne  in  mind  in  connection  with  pylorospasm  in  adults;  and 
the  similarity  pointed  out  by  Meinhard  Schmidt  between  the  former 
condition  and  blepharospasm,  vaginismus,  tenesmus  ani,  etc.,  should 
not  be  forgotten. 

Pylorospasm  is  really  only  a  symptom  of  some  other  malady, 
or  of  one  of  a  number  of  diseases  met  with  in  the  upper  abdomen. 
It  will  be  noted  that  in  the  definition  of  pylorospasm  already  given 
it  was  stated  to  be  an  intermittent  or  constant  contraction  of  the 
sphincter.  It  is  very  rarely  a  remittent  contraction:  that  is  to 
say,  the  spasm  may  occur  only  once  or  twice  in  a  person's  Hfetimc — 
it  may  be  a  spasm  which  "comes  back  at  times";  or  it  may  be, 
and  more  frequently  is,  an  intermittent  contraction — one  which 
"goes  away  at  times";  and  in  rare  instances  the  spasm  may  be 
constant  for  a  period  of  two  or  three  days  or  longer,  without  any 
intermission.  The  first  form  is  that  which  is  a  frequent  accom- 
paniment of  gall-stone  colic;  and  may  occur  in  other  acute  aflfec- 
tions  of  the  up})er   abdomen,    being    here,  as  under  other  circum- 


Pylorospasm.  145 

stances,  merely  a  symptom  of  an  organic  lesion  of  the  alimentary 
canal. 

In  many  cases  the  pain  of  the  cramp  is  not  very  great,  amount- 
ing merely  to  a  lively  sense  of  discomfort  in  the  epigastric  region, 
and  being  overshadowed  by  symptoms  of  "peristaltic  unrest  of 
the  stomach,"  so  graphically  described  by  Kussmaul  ("embarras 
gastrique"  of  the  French).  When  the  pylorus  contracts  spasmod- 
ically, from  whatever  source  of  irritation  there  may  be  present, 
the  stomach  meets  with  an  insuperable  obstacle  to  its  evacuation. 
Peristaltic  unrest  ensues,  flatulence  developes  from  fermentation 
and  from  swallowed  air,  and  finally,  when  the  limit  of  endurance 
is  reached,  the  pylorus  relaxes  and  gastric  contents  pass  out  into 
the  duodenum,  or  the  patient  is  relieved  of  his  distress  by  vomiting, 
and  comparative  comfort  is  restored. 

Such  a  crisis  as  this  may  occur,  as  already  remarked,  only  once 
or  twice  in  a  patient's  hfetime;  or  it  may  be  the  habitual  sequel  to 
every  meal.  The  symptoms  may  vary  from  those  of  the  mildest 
gastric  indigestion,  to  the  most  awful  and  overwhelming  pain  in 
the  region  of  the  pylorus.  The  pain  attendant  on  cramp  of  the 
gall-bladder;  that  encountered  in  patients  with  vesical  tenesmus 
from  enlarged  prostate,  stone,  severe  cystitis,  or  sclerosis  of  the 
neck  of  the  bladder;  the  more  frequently  seen  colic  of  the  intes- 
tines— these  are  all  symptoms  of  disease  in  the  part  affected,  as  is 
pylorospasm  of  disease  in  the  upper  abdomen. 

It  is  not  always  possible  to  determine  just  what  is  the  under- 
lying disease  in  cases  of  pylorospasm.  It  is  probably  more  often 
due  to  an  erosion  or  ulcer  of  the  stomach  or  pyloric  antrum  than 
to  any  other  single  affection;  but  as  already  remarked,  it  is  a  fre- 
quent accompaniment  of  affections  of  the  gall-bladder;  and  may 
be  the  only  distinctive  symptom  in  patients  with  polypus  of  the 
stomach.  Until  further  investigation  teaches  us  more,  we  must 
be  content  in  the  majority  of  cases  to  treat  the  condition  empirically. 

If  the  pylorospasm  persists,  intermittently,  over  a  long  period, 
it  is  wont  to  be  accompanied  by  symptoms  of  Reichmann's  disease — 
excessive  secretion  of  the  stomach,  gastro-succorrhcea ;  but  whether 
this  disease  is  a  sequel  or    a  cause  of   pylorospasm  physicians  are 


146       Benign  Diseases  of  the  Stomach  and  Duodenum. 

not  agreed;  and  a  further  discussion  of  the  subject  would  be  out 
of  place  in  a  work  of  this  kind.  Gastric  dilatation  may  also 
follow;  and  it  would  not  be  improbable  that  hypertrophy  of  the 
pyloric  sphincter  might  be  a  sequel  of  long  standing  p3dorospasm 
in  some  patients,  though  we  are  not  aware  that  such  a  change  has 
ever  been  demonstrated.  The  most  intelligible  description  of  these 
allied  conditions,  with  which  we  are  acquainted,  is  to  be  found 
in  VanValzah  and  Nisbet's  "Diseases  of  the  Stomach"  (London, 
1900),  and  to  it  the  reader  who  desires  further  information  on  the 
subject  is  respectfully  referred. 

Pylorospasm  should  first  be  treated  energetically  by  medical 
means;  and  in  cases  where  reasonable  persistence  along  this  line 
fails,  surgical  intervention  must  be  considered.  If  the  stomach 
be  not  enlarged,  and  its  motility  remain  good,  pyloroplasty,  or  prefer- 
ably Finney's  operation,  may  be  expected  to  give  good  results. 
But  in  most  patients  seen  by  the  surgeon  gastric  dilatation  is  so  pro- 
nounced that  only  gastro-jejunostomy  can  be  expected  to  cure. 

REFERENCES. 

Hemmeter:    Diseases  of  the  Stomach,  2nd  Edition,  Philadelphia,  1902,  p. 

744- 
Kussmaul:  Volkmann's  Samml.  klin.  Vortr.,  1880,  No.  181. 
Schmidt,  M.:   Arch.  f.  khn.  Chir.,  1901,  Ixiii,  976. 

Gastric  Dilatation. 

Although  the  interest  of  the  surgeon  in  gastric  dilatation  is  usually 
confined  to  those  forms  which  are  strictly  secondary  in  origin,  and 
which  are  in  the  immense  majority  of  cases,  if  not  in  all,  produced  by 
pyloric  obstruction;  and  althougli  for  this  reason  it  has  seemed  best  to 
discuss  the  subject  untk'r  the  general  heading  of  olxslruction  of  the 
pylorus,  yet  there  are  certain  forms  of  dilatation  of  the  stomach  which 
have  of  late  years  come  within  the  surgical  horizon,  and  yet  which  arc 
not  technically  due  to  obstruction  of  the  pylorus.  We  refer  to  acute 
dilatation  of  tlie  stomach,  and  to  tlie  form  known  to  ])hysicians  as 
atonic  dilatation  or  gastric  myasthenia. 

Both  of  these  affections  are  in  their  essence  medical,  inasmuch 


Acute  Dilatation  of  the  Stomach.  147 

as  we  must  believe  with  our  present  knowledge  that  they  are  usually 
functional  disturbances.  But  since  even  in  some  diseases  formerly 
thought  to  be  functional,  surgery  has  of  late  years  brought  about 
a  cure  by  improving  the  mechanical  power  of  the  organ  concerned, 
and  as  in  these  very  affections — acute  and  atonic  dilatation  of  the 
stomach — operations  are  occasionally  of  benefit  after  purely  medical 
treatment  has  been  proved  of  no  avail,  a  short  discussion  of  the 
symptoms  encountered  and  of  the  surgical  treatment  which  may 
be  called  for,  is  surely  a  suitable  addition  to  a  treatise  on  the  surgery 
of  the  upper  abdomen. 

Acute  Dilatation  of  the  Stomach,  first  brought  to  the  atten- 
tion of  the  medical  world  in  1872  by  Hilton  Fagge,  has  been  re- 
cently discussed  in  elabourate  articles  by  Neck,  by  Conner,  and  by 
Laffer,  who  has  collected  217  cases.  It  is,  as  already  remarked, 
primarily  a  medical  disease.  It  is  met  with  as  a  complication  in 
various  infectious  diseases,  such  as  pneumonia  and  typhoid  fever, 
but  occasionally  seems  to  arise  as  a  primary  affection,  the  patient 
being  suddenly  seized  with  symptoms  of  obstruction,  and  there  being 
no  preceding  disease  of  any  kind.  More  often,  however,  and  this 
is  what  has  drawn  surgical  attention  to  it,  the  dilatation  developes 
as  a  post-operative  complication,  and  in  many  cases  terminates 
fatally  within  twenty- four  to  forty-eight  hours.  The  preceding  opera- 
tion is  by  no  means  always  an  abdominal  one.  Operations  on  the 
extremities,  on  the  kidneys,  and  on  other  parts  of  the  body  have  been 
followed  by  acute  dilatation  of  the  stomach ;  a  large  number  of  post- 
operative cases  have  followed  operations  on  the  biliary  tract. 

Causes. — Various  theories  have  been  advanced  to  explain  the 
condition,  and  their  number  shows  that  no  one  can  be  considered 
wholly  sufficient  to  explain  its  developement  under  the  different 
circumstances  in  which  it  is  encountered.  As  predisposing  causes 
have  been  recognized  atonic  dilatation  of  the  stomach;  pyloric 
obstruction  whether  associated  or  not  with  chronic  gastrectasis ; 
overfilling  of  the  stomach  with  food  or  drink  (lemonade  and  cham- 
pagne have  in  some  patients  been  accused  as  exciting  causes) ;  pre- 
existing toxaemias  (typhoid  fever,  pneumonia,  etc.);  and  lastlv 
surgical  operations.      Routier  apparently   thinks  all    postoperative 


148       Benign  Diseases  of  the  Stomach  and  Duodenum. 

cases  are  to  be  attributed  to  septic  intoxication  ;  but  it  must  be 
acknowledged,  if  this  is  true,  that  in  most  instances  none  of  the 
usual  signs  of  sepsis  are  present.  ■Most  patients  are  between 
twenty  and  thirty  years  of  age.  Zade  adds  to  the  predisposing 
causes  already  mentioned,  that  of  abnormal  length  of  the  mesen- 
tery, or  a  position  of  the  small  bowels  in  the  pelvis,  thus  puUing  on 
the  mesentery.  Indeed  the  theory  proposed  by  Hanau-Albrecht  in 
1899,  that  acute  gastric  dilatation  is  due  to  constriction  of  the 
duodenum  by  the  superior  mesenteric  artery,  through  dragging 
on  the  root  of  the  mesentery,  has  received  more  support  of  late 
vears  than  anv  other.  But  most  authors  think  that  the  dilatation 
is  primary,  and  that  it  is  merely  increased  by  kinking  of  the  pylorus 
or  bv  the  distended  stomach  itself  pressing  on  and  occluding  the 
duodenum.  The  observations  of  Kelhng  and  others,  referred  to  in 
Chapter  II,  as  to  the  gastro-duodenal  reflex,  by  which  evacua- 
tion of  the  stomach  is  prevented  by  distention  of  the  duodenum, 
have  probably  a  close  bearing  on  this  subject;  and  since  in  many 
cases  which  have  come  to  autopsy  there  has  been  found  (Neck) 
some  obstruction  to  the  duodenum  at  its  junction  with  the  jejunum, 
and  but  rarely  has  there  been  found  pyloric  obstruction,  it  seems 
only  fair  to  conclude  that  the  mechanical  obstruction  thus  produced 
is  at  least  as  sufficient  an  explanation  as  is  the  assertion  that  the 
dilatation  is  primary,  or  due  to  some  lesion  of  the  pneumogastric 
nerves,  as  suggested  by  Carrion  and  Hallon.  Laffer  also  supports 
this  theory.  It  is  not  imj^robable,  we  admit,  that  in  those  cases 
of  acute  gastric  dilatation  dcAX-loping  after  operations  on  the  biliary 
tract,  there  may  have  been  produced  some  reflex  disturbances  of 
gastric  innervation  by  way  of  the  spkmchnics  and  the  liepatic 
plexus;  yet  we  are  totally  unable  to  see  how  a  similar  explanation 
could  by  any  stretch  of  the  imagination  be  considered  ai)plicablc 
to  the  cases  of  those  jjatients  who  had  had  oi)crations  performed 
on  their  lower  extremities.  It  appears  to  us  that  it  is  a  much 
more  likely  thing  that  the  aniesthetizalion,  and  the  lifting  of  the 
j;alicnt  on  and  off  the  stretcher  and  the  operating  table,  added 
to  the  frequently  unusual  and  strained  positions  in  which  patients 
he   fluring  and    after  operation,    are   all    factors    which  would  tend 


Acute  Dilatation  of  the  Stomach.  149 

to  produce  an  enteroplosis  of  the  small  intestines,  or  would  in  some 
way  produce  a  kink  at  the  duodeno-jejunal  flexure,  and  so  would 
be  productive  of  the  state  of  affairs  usually  found  in  connection 
with  acute  gastric  dilatation.  Added  to  these  causes,  which  might 
be  present  in  every  post-operative  case,  would  be  the  direct  inter- 
ference with  the  viscera  in  abdominal  operations  of  all  kinds. 
Especially  would  this  be  the  case  in  operations  on  the  bile  passages, 
where  the  duodenum  and  small  intestines  are  constantly  pressed 
by  gauze  pads  out  of  their  normal  relations;  and  in  operations 
for  the  removal  of  large  ovarian  cysts  or  myomatous  uteres,  where 
the  small  intestines  would  naturally  fall  into  the  emptied  pelvis 
and  occupy  a  position  which  in  that  individual  patient  would  be 
strange  and  unusual.  This  theory  has  been  ably  supported  by  P. 
Miiller.  Seehg  has  suggested  that  the  application  of  a  very  tight 
abdominal  binder  may  favour  the  occurrence  of  acute  gastric  dilata- 
tion, because  although  the  small  intestines  hiay  work  their  way  by 
peristalsis  down  into  the  pelvis  under  such  'an  obstruction,  they  will 
be  unable  to  get  back  again,  and  as  they  accumulate  in  the  lower 
abdomen  will  render  the  root  of  the  mesentery  taut. 

Of  the  102  cases  analyzed  by  Conner,  42  (41  per  cent.)  followed 
operations  in  which  general  anaesthesia  was  employed  (15  opera- 
tions on  gall-bladder,  etc.;  17  after  other  abdominal  operations; 
10  after  operations  not  involving  the  abdomen);  other  cases  were 
observed  during  or  after  severe  diseases  (typhoid  fever,  pneumonia, 
etc.);  others  after  injuries;  others  after  indiscretions  in  diet;  six 
were  associated  with  disease  or  deformity  of  the  spine,  and  four 
appeared  to  be  idiopathic  in  origin.  One  patient  with  typhoid 
fever,  who  died  from  acute  dilatation  of  the  stomach,  has  come 
under  the  notice  of  Dr.  Ashhurst  at  the  Episcopal  Hospital,  in  the 
service  of  Charles  H.  Weber. 

Pathology. — The  stomach  is  found  to  fill  practically  the  whole 
abdomen.  Its  shape  is  characteristic,  presenting  usually  a  marked 
V-shaped  depression  in  the  lesser  curvature,  and  approximating 
the  form  found  in  gastroptosis,  especially  that  due  to  deformity 
from  tight  lacing,  though  very  much  more  pronounced.  As  pointed 
out  in  the  previous  paragraphs,  a  site  of  obstruction  has  most  fre- 


150       Benign  Diseases  of  the  Stomach  and  Duodenum. 

quently  been  found  in  the  neighbourhood  of  the  duodeno-jejunal 
flexure,  or  else  where  the  superior  mesenteric  artery  crosses  the 
duodenum.  Among  120  cases  which  came  to  autopsy,  Laffer 
states  that  there  was  obstruction  of  the  duodenum  by  the  root  of 
the  mesentery  in  27.  The  duodenum  as  far  as  the  point  of  con- 
striction is  frequently  much  dilated.  There  is  rarely  any  obstruc- 
tion at  the  pylorus,  unless  it  is  manifestly  due  to  a  kink  produced 


Fig.  20. — Campbell  Thompson's  Case  of  Acute  Dilatation  of  the  Stomach. 


by  the  descent  of  the  stomach.  'J"hc  lUiid  contents  of  the  stomach 
are  due  to  hy]jersecretion,  as  well  as  to  mere  accumulation  from 
obstruction  of  its  outlets,  liui  the  ])resence  of  the  immense  quanti- 
ties of  gas,  and  its  rapid  re-accumulation  after  lavage  are  not  so 
easily  explained.  The  gas  is  no  (loiil)t  in  large  ])art  due  to  fer- 
mentation, and  some  of  it  is  swallowed,  as  in  the  nervous  affection 
known    as    acro])hagia.     I'ut    to   accf)unl    foi-   the    re  accumulation 


Acute  Dilatation  of  the  Stomach.  151 

of  gas  in  so  short  a  space  of  time,  some  authors  have  held  that  gas 
was  produced  by  transudation  from  the  blood  vessels  in  the  stomach 
walls.  Whether  this  is  in  accord  with  modern  physiological  views 
we  do  not  know,  but  it  appears  to  be  a  far-fetched  explanation. 
Gas-producing  bacteria  have  been  found  in  the  stomach  contents, 
according  to  some  reports. 

There  is  as  a  rule  no  peritonitis;  and  the  site  of  operation,  if 
an  abdominal  operation  had  been  performed,  usually  presents  no 
deviations  from  the  normal.  Some  writers  have  confused  tym- 
panitic distension  of  the  stomach  from  peritonitis,  with  acute  dila- 
tation of  the  stomach.  In  the  former  condition,  which  is  by  no 
means  so  rare  as  acute  dilatation,  the  whole  intestinal  tract  may 
be  much  dilated,  but  the  stomach,  being  the  largest  hollow  organ, 
is  apparently  disproportionately  dilated;  hence  the  confusion. 

Symptoms. — The  symptoms  of  this  malady  cannot  be  said  to 
be  always  very  distinct  or  readily  recognized.  Usually  the  onset 
is  sudden  in  character,  and  may  begin  from  twelve  to  twenty- 
four  hours  after  the  operation,  although  in  many  instances  no 
symptoms  have  developed  until  convalescence  was  thought  to  be 
assured.  The  patient's  first  complaint  is  generally  pain,  referred 
to  the  epigastrium,  with  a  sense  of  distention.  Vomiting  occurs 
promptly,  with  comparatively  little  nausea;  and  large  amounts 
of  dark  greenish  fluid  are  gulped  up  without  straining.  The  vom- 
itus  is  almost  never  fcecal,  and  is  seldom  very  offensive.  Bile  and 
blood  may  be  present,  but  usually  the  vomited  matters  are  com- 
posed chiefly  of  gastric  secretion  and  mucus,  and  present  a  charac- 
teristic smell.  Vomiting  generally  persists  to  the  end,  whether  this 
be  the  death  or  the  recovery  of  the  patient. 

The  distention  of  the  abdomen  may  be  readily  recognized  by 
the  eye,  being  most  prominent  to  the  left  of  the  median  line. 
When  the  stomach  tube  is  passed  there  is  an  abundant  escape  of 
odourless  gas,  with  a  gushing  or  a  gurgling  sound,  even  at  times 
almost  an  explosion;  and  a  marked  flattening  of  the  abdomen 
usually  follows  evacuation  of  the  stomach  by  this  means.  But 
within  a  very  short  time  after  the  stomach  has  been  emptied  it  refills 
again,  with  secretion  and  air,  and  the  patient's  distress  is  as  great  as 


152       Benign  Diseases  of  the  Stomach  and  Duodenum, 

ever.  Peristalsis  is  extremely  rare,  having  been  observed  only  once, 
by  Schultz,  according  to  Robson  and  Moynihan.  Palpation  finds 
the  abdominal  walls  not  rigid,  as  in  peritonitis,  but  merely  tense 
from  the  tension  within.  A  splashing  sound  is  readily  obtained 
from  the  stomach  contents,  and  is  usually  too  distinct  for  there 
to  be  any  doubt  that  it  comes  from  an  air-containing  cavity.  The 
distention  of  the  stomach  is  extreme,  the  greater  curvature  always 
reaching  well  below  the  umbilicus,  and  frequently  extending  to 
the  peh'is.  Percussion  detects  a  tympanitic  note  over  the  most 
prominent  portion  of  the  distended  stomach,  and  the  usual  change 
of  level  in  the  diilness  produced  by  fluid  can  be  obtained  by  turning 
the  patient  to  one  side. 

Along  with  these  local  signs,  the  general  condition  of  the  patient 
is  seen  to  have  taken  a  sudden  turn  for  the  worse.  There  is  usually 
little  fever,  but  the  pulse  becomes  thready  and  rapid,  the  eyes 
sunken  and  bright,  the  tongue  heavily  coated,  the  breath  foul,  the 
mind  delirious  or  comatose,  and  dissolution  appears  imminent.  In 
short  the  evidences  of  toxaemia  are  pronounced. 

In  milder  cases  of  the  same  nature,  the  stomach  is  relieved  by 
lavage  or  by  vomiting;  and  occasionally  a  profuse  diarrhoea  is 
the  first  symptom  that  the  obstruction  has  been  overcome.  In 
Roussel's  patient  there  were  from  25  to  35  extremely  offensive 
movements  daily.  It  is  much  better  to  remove  the  secretions  l^y 
lavage,  since  sometimes  fatal  absorption  from  the  small  intestines 
will  kill  a  patient  in  whom  the  subsidence  of  the  dilatation  of  the 
stomach  and  the  evident  onward  passage  of  its  contents  had  gix'cn 
rise  to  hopes  of  recovery. 

Differentia]  Diagnosis.  —  It  is  imporlant  that  the  surgeon 
should  not  mistake  the  vomiting  caused  by  acute  dilatation  of  tlie 
.stomach  for  that  due  to  the  an;csthetic.  In  the  former  the  symj)- 
toms  usual!}'  do  not  arise  until  all  Jiausca  from  the  ana'sthctic  has 
suljsided;  but  occasionally  when  the  post-operative  nausea  is 
.severe  and  long  continued  the  condition  may  pass  into  that  of 
acute  gastric  dilatation  without  any  pronounced  change  in  symp- 
toms. Peritonitis  is  frcqufntl\-  thought  of  when  the  s\-n'i])t()ms  of 
acute  gastric  dilatation  commence.     The    |)eriocI    of   onset   of  both 


Acute  Dilatation  of  the  Stomach.  153 

frequently  is  similar,  but  the  signs  are  not  the  same.  Not  only  is 
the  pain  of  a  different  character,  being  rather  burning  than  sharp; 
but  the  physical  evidences  of  a  large  amount  of  fluid,  and  above 
all  the  presence  of  the  succussion  splash,  will  at  once  show  that 
peritonitis  alone  is  not  the  condition  present.  Furthermore,  the 
evacuation  of  the  gas  and  other  stomach  contents  with  the  sub- 
sidence of  the  abdominal  distention,  which  follow  the  passage  of 
the  stomach  tube,  confirm  the  diagnosis,  and  usually,  for  a  time 
at  least,  produce  a  remission  of  S3^mptoms.  Neither  peritonitis 
nor  intestinal  obstruction  will  be  so  affected.  Finally,  the  nature 
of  the  preceding  operation,  or  the  previous  course  of  the  disease 
when  no  operation  has  been  performed,  may  be  sufficient  to  ex- 
clude both  peritonitis  and  intestinal  obstruction.  Thus  operations 
on  the  kidneys  or  the  extremities,  and  even  many  abdominal 
operations,  such  as  those  for  the  radical  cure  of  hernia,  could  under 
no  normal  circumstances  be  productive  of  peritonitis. 

Prognosis. — Among  the  217  cases  of  this  affection  collected 
by  Laffer,  135  patients  died,  some  within  a  few  hours;  but  a  few 
survived  into  the  second  week.  One  lived  thirteen  days.  Seventy- 
seven  patients  are  known  to  have  recovered;  and  in  5  the  result 
is  not  recorded.  Any  disease  with  a  death  rate  of  over  63  per  cent, 
must  be  considered  extremely  grave. 

Treatment. — As  in  other  affections  whose  pathology  is  not 
well  understood,  so  in  acute  dilatation  of  the  stomach,  treatment 
must  be  largely  empirical.  Lavage  of  the  stomach  is  the  first 
indication.  As  Terrier  has  said,  it  is  only  a  matter  of  common 
sense  to  empty  an  over-distended  stomach.  Regnier  indeed  em- 
ploys lavage  as  a  preventative  of  this  complication,  and  at  the  first 
vomiting,  the  first  hiccough,  or  change  of  expression,  or  increase 
in  the  pulse  rate,  at  once  washes  the  patient's  stomach  out.  The 
idea  which  seems  to  possess  the  minds  of  a  great  many  surgeons, 
that  toxaemic  symptoms  after  operation  are  due  to  stagnation  in 
and  absorption  from  the  stomach,  we  think  is  in  no  way  justified. 
Absorption  from  the  stomach  is  so  extremely  slight  that  it  seems 
doubtful  that  any  recognizable  symptoms  of  toxaemia  can  be  pro- 
duced in  this  way;  but  the  importance  of  preventing  the  passage 


154       Benign  Diseases  of  the  Stomach  and  Duodenum. 

of  these  secretions  into  the  small  intestine,  whence  absorption  is 
rapid,  has  already  been  alluded  to.  Whatever  the  theory  be, 
certainly  the  practice  of  washing  the  stomach  is  attended  by  the 
happiest  results  in  all  such  cases.  Yet  it  should  not  be  made  too 
much  a  matter  of  routine.  Some  patients  will  be  so  exhausted 
and  nervously  prostrated  by  the  passage  of  a  stomach  tube  that 
much  more  harm  than  good  will  ensue.  It  appears  to  us  to  be 
quite  sufficient  to  employ  lavage  only  when  a  distinct  therapeutic 
end  is  to  be  attained.  If  every  patient  who  hiccoughed  or  puked 
after  an  operation  were  to  be  submitted  to  lavage,  the  number  who 
escaped  such  treatment  would  be  inappreciable.  Let  lavage  not 
be  used  until  it  is  certain  that  the  stomach  cannot  take  care  of 
itself;  and  then  do  not  let  any  timidity  prevent  its  employment 
even  in  patients  who  have  been  operated  on  by  such  methods  as 
gastro-enterostomy  or  pylorectomy. 

In  case  acute  dilatation  of  the  stomach  is  not  promptly  relieved 
by  the  first  lavage,  not  only  should  this  treatment  be  repeated,  but 
the  patient  should  be  made  to  lie  on  the  left  side,  with  the  foot  of 
the  bed  raised  so  as  to  bring  the  pelvis  higher  than  the  diaphragm. 
This  failing  to  secure  rehef,  the  "belly  position"  may  be  tried. 
In  persistent  cases,  and  where  the  nature  of  the  operation  does 
not  contraindicate  it,  the  patient  should  be  made  to  assume  the 
knee-chest  position  for  fifteen  minutes  out  of  every  two  hours,  as 
recommended  Ijy  Zafle.  When  such  an  operation  has  not  already 
been  performed,  gastro-jejunostomy  may  be  employed  as  a  last 
resort.  Of  course,  if  on  opening  the  abdomen,  a  kink  at  the  py- 
lorus or  at  the  duodeno-jejunal  juncture  be  found,  which  can  be 
relieved  without  furlluT  interference,  the  surgeon  sliould  content 
himself  with  that;  but  in  most  of  the  reported  cases  it  lias  been 
evident  that  no  such  simple  ])rocedure  would  have  been  productive 
of  benefit.  The  operation  ])r()])osed  ])y  Robinson — section  of 
the  duodenum  and  its  reunion  in  front  of  the  mesenteric  A'cssels — 
is,  as  said  by  Finney,  a  thoroughly  unpractical  ])rocedure. 

Operative  treatment  of  acute  <rastric  dilatation  appears  to  have 
been  arloptcd    in  fourteen   cases,  with    a  mortality  of    over    85    per 


Acute  Dilatation  of  the  Stomach.  155 

cent.     The    operations    employed    may  be    seen    in    the    following 
table. 


OPERATIONS  FOR  ACUTE  DILATATION  OF  THE 
STOMACH. 

I.  Exploratory  Laparotomy:  Abdomen  closed  without  empty- 
ing Stomach. 

Jessop  (Lancet,  1888,  i,  726) :   Death, 

Robinson  (Cincinnati  Lancet- Clinic,  1900,  xlv,  577) :  Death. 
II,  Exploratory  Laparotomy,  with  emptying  of  Stomach  by  tube 
passed  through  (Esophagus,  diagnosis  not  having 
been  made  before  operation. 

Macevitt  (N.  Y,  State  Jour,  of  Med.,  igo6,  vi,  284): 
Recovery. 

Turner  (Appendicitis,  Hernia,  and  Gastric  Ulcer.  Lon- 
don, 1905,  p.  113):    Death. 

III.  Reduction  of  Volvulus,  dilatation  of  Stomach  not  being  found 

at  Operation. 
Lichtenstein   (Zentralbl.  f.  Gynak.,  1906,  No.  44):  Death. 

IV,  Jejunopexy — kink    of    duodeno-jejunal    flexure    relieved    by 

suturing  jejunum  to  transverse  mesocolon. 

Petit    (These    de    Paris,  1900;    cited   by    Conner:    Amer, 
Jour.  Med,  Sc,  1907,  i,  345) :    Recovery. 
V,  Gastrotomy. 

Appel  (Phila.  Med.  Jour.,  1899,  iv,  314):   Death. 

Box  and  Wallace  (Lancet,  1898,  i,  1538):   Death. 

Finney  (Bost.  Med.  and  Surg.  Jour.,  1907,  civ,  107):   Death. 

Hoffmann    (Miincli.   med.   Woch.,    1904,  li,  2003) :  Death. 

Wright  (Practitioner,  1897,  vi,  598) :    Death. 
VI.  Gastrostomy,  the  dilated  Stomach  being  mistaken  for  a  pan- 
creatic cyst. 

Brown  (Lancet,  1899,  ii,  1017):    Death. 
VII.  Gastro-jejunostomy. 

Kehr  (Arch.  f.  klin.  Chir.,  1897,  Iviii,  632):  Death. 

Korte  (Deutsch.  med.  Woch.,  1904,  xxx,  1554) :   Death. 

REFERENCES. 

Carrion  and  Hallon:   Semaine  Med.,  1895,  21  aug. 
Conner:  Amer.  Jour.  Med.  Sc,  1907,  i,  345. 
Fagge:    Guy's  Hospital  Reports,  1872,  xviii,  i. 
Finney:  Bost.  Med.  and  Surg.  Jour.,  1907,  civ,  107. 


156        Benign  Diseases  of  the  Stomach  and  Duodenum. 

Hanau-.\lbrecht:   Virchow's  Archiv  f.  path.  Anat.,  1899,  cha,  285. 

Laffer:  Annals  of  Surgery,  1908,  i,  390. 

Muller,  P.:   Deulsch.  Zeit.  f.  Chir.,  1900,  Ivi,  486. 

Neck:   Centralbl.  f.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1905,  viii,  529. 

Robinson:   Cincinnati  Lancet-Clinic,  1900,  xlv,  577. 

Roussel:  N.  Y.  Med.  Record,  1908,  i,  136. 

Routier:   Semaine  Med.,  1905,  xxv,  571. 

Seelig:  Interstate  Med.  Jour.,  St.  Louis,  1907,  xiv,  517. 

Terrier:   Semaine  Med.,  1905,  xxv,  571. 

Zade:   Beitr.  z.  klin.  Chir.,  1905,  xlvi,  388. 


Atonic  Dilatation  of  the  Stomach.  157 

Atonic  Dilatation  of  the   stomach,    or   Gastric    Myasthenia, 

though  formerly  a  well  recognized  affection  of  the  stomach,  has  of 
late  years  become  a  disease  of  the  utmost  rarity.  This  is  largely 
due  to  the  increased  accuracy  in  diagnosis  of  gastric  affections  to 
which  physicians  have  attained,  but  in  no  small  measure  is  it  due 
to  modern  surgery  which  has  proved  by  the  living  pathology  of  the 
operating  table  that  most  of  the  cases  formerly  classed  as  atonic 
dilatation  are  really  examples  of  gastric  dilatation  due  to  well  de- 
fined lesions,  chiefly  to  pyloric  obstruction  from  carcinoma,  ulcera- 
tion or  perigastric  adhesions.  There  is,  of  course,  no  inherent 
improbability  in  the  muscular  wall  of  the  stomach  losing  its  strength, 
just  as  we  know  that  of  the  sigmoid  flexure  or  of  the  colon  higher 
up  sometimes  does;  and  just  as  we  meet  with  cases  of  so-called 
atony  of  the  bladder.  Before  diagnosis  in  urinary  diseases  was 
as  fully  developed  as  it  is  now,  patients  with  atony  of  the  bladder 
were  frequently  seen;  but  since  diseases  of  the  prostate  have  be- 
come more  widely  studied,  and  since  sclerosis  of  the  neck  of  the 
bladder  has  become  a  surgical  entity,  the  cases  in  which  the  diag- 
nosis of  atony  of  the  bladder  is  made  have  become  correspondingly 
decreased  in  number.  Indeed,  for  our  own  part,  were  we  to  en- 
counter again  a  patient  with  pure  atony  of  the  bladder,  from  no 
recognizable  lesion  other  than  pure  weakness  of  the  vesical  walls, 
or  impairment  of  innervation,  we  should  be  rather  disposed  to 
question  our  own  diagnostic  acumen  than  to  admit  that  such  a 
state  of  affairs  actually  existed.  So  it  is  with  cases  of  gastric  myas- 
thenia. There  is  no  doubt  that  after  such  debilitating  disease 
as  typhoid  fever  the  gastric  walls  may  become  weakened,  and 
become  readily  subject  to  distention  and  dilatation  when  over- 
loaded; but  even  in  cases  such  as  these,  there  is  no  good  reason 
to  suppose  that  recovery,  if  not  attained  by  medical  measures,  may 
not  be  aided  by  operative  means.  Long-standing  gastritis,  ori- 
ginally catarrhal  in  form,  may  eventually  invade  the  submucosa, 
thickening  and  hardening  the  gastric  walls,  and  thus  materially 
interfering  with  peristalsis.  In  the  same  manner,  but  even  more 
noticeably,  ulcerations,  cancerous  growths,  and  even  the  ingestion 
of  poisons,  may  greatly  impair  gastric  motility  without  in  any  way 


158       Benign  Diseases  of  the  Stomach  and  Duodenum. 

producing  stenosis  of  the  pylorus.  It  is  not  impossible  that  the 
gastric  nerves  may  be  the  seat  of  disease,  without  there  being  any 
change  in  the  gastric  wall  itself,  and  that  by  this  means  dilatation 
may  ensue  from  loss  of  motility.  But  such  a  change  is  probably 
much  rarer  than  it  has  heretofore  been  considered.  Actual  degenera- 
tive changes  (colloid,  fatty,  etc.)  in  the  muscle  fibres  of  the  gastric 
walls  are  probably  of  less  unfrequent  occurrence. 

In  patients  with  this  form  of  gastric  dilatation,  the  absence  of 
distinct  history  is  the  chief  means  of  differentiating  the  disease 
from  that  form  due  to  pyloric  stenosis.  The  symptoms  for  which 
the  patient  seeks  relief  are  the  same  in  kind,  though  probably  less 
in  degree,  than  in  pyloric  stenosis.  The  sense  of  fullness  persist- 
ing from  one  meal  to  the  next,  the  anorexia,  the  thirst,  the  gaseous 
distention,  and  the  eructation — all  are  the  same  in  both  affections. 

Three  stages  of  gastric  myasthenia  may  be  recognized.  The 
first  is  the  stage  of  compensation,  the  second  that  of  stagna- 
tion, and  the  third  that  of  retention.  Early  in  the  disease  the 
symptoms  are  not  of  such  prominence  as  to  fix  themselves  in  the 
patient's  mind;  it  is  only  after  an  unusually  heavy  meal,  or  after 
a  particularly  indigestible  one,  that  he  is  made  aware  of  his  dyspep- 
sia. The  gaseous  distention  then  becomes  oppressive,  the  clothing 
is  perhaps  unconsciously  loosened,  and  relief  is  eventually  obtained 
by  the  belching  of  gas,  or  by  the  lazy  emptying  of  the  wearied  stom- 
ach into  the  duodenum.  Not  unfrequently  a  little  sour  fluid  rises 
into  the  mouth  along  with  the  gas  (VanValzah  and  Nisbct).  But 
in  this  stage  compensation  is  generally  sufficient,  and  these  periods 
of  broken  compensation  arise  only  when  some  unusual  strain  is 
thrown  u])on  the  stomach.  This  stage  may  last  for  months  or 
years;  but  it  is  exceedingly  prone  to  pass  into  the  second  stage- 
that  of  gastric  stagnation,  a  condition  in  which  the  stomach  is 
unable  completely  to  evacuate  its  contents  between  meals,  except 
between  the  evening  meal  and  breakfast,  an  interval  sufliciently 
great  for  evacuation  to  be  accomplished.  'Jlie  patient  finds  it 
impossible  to  gain  in  weight,  though  it  is  not  usual  for  weight  to 
be  lost.  Digestion,  tliough  dehiyed,  is  ewntually  completed. 
When,  however,  the  third  stagt',  tlial  of  retention,  is  reached,  ema- 


Atonic  Dilatation  of  the  Stomach,  159 

ciation  commences  and  may  become  extreme.  The  stomach  is 
not  emptied  even  during  the  night,  and  lavage  before  breakfast 
will  detect  particles  of  food  still  in  the  stomach;  and  the  gastric 
contents  will  possess  the  usual  characteristics  of  retention — they 
will  be  sour,  rancid,  and  usually  very  acid.  Occasionally,  when 
atrophy  of  the  mucous  membrane  is  present,  the  contents  are 
neutral  or  alkaline  in  reaction.  The  evidences  of  fermentation 
are  pronounced,  and  the  production  of  gas  will  continue  often- 
times after  the  stomach  contents  have  been  removed  by  lavage, 
as  is  evidenced  by  the  separation  of  these  contents  into  the  usual 
three  layers.  The  dilated  stomach,  by  dragging  on  the  pylorus, 
causes  a  kinking  near  the  latter,  thus  adding  the  mechanical  factor 
of  actual  obstruction  to  the  myasthenia  which  was  the  primary 
cause  of  the  dilatation. 

Secondary  nervous  symptoms  are  of  common  occurrence  in 
patients  suffering  from  gastric  retention  due  to  atonic  dilatation. 
As  pointed  out  by  Van  Valzah  and  Nisbet,  the  source  of  these 
symptoms  is  to  be  found  in  intestinal  toxaemia.  The  intestines 
partake  of  the  atony  which  affects  the  stomach,  and  it  is  precisely 
because  there  is  no  pyloric  obstruction  that  the  fermenting  gastric 
contents  in  part  reach  the  small  bowels,  and  are  thence  absorbed. 
Where  the  gastric  dilatation  is  due  merely  to  mechanical  obstruction 
at  the  pylorus,  this  obstruction  itself  protects  the  small  bowels  from 
the  decaying  food,  and  the  various  symptoms  of  hypochondriasis, 
hallucinations,  dyspnoea,  tachycardia,  urticaria,  erythema  fugax,  and 
other  toxemic  affections  are  the  exception  rather  than  the  rule. 

Treatment. — The  treatment  of  gastric  myasthenia  in  its  earlier 
stages  should  be  medical.  If  the  first  stage  be  recognized  it  often- 
times may  be  cured,  or  the  developement  of  the  second  may  at 
least  be  indefinitely  postponed,  by  regulation  of'  the  diet  and  tonic 
treatment.  During  the  second  stage,  in  addition  to  the  above, 
lavage  is  indicated;  and  electricity  may  be  employed  with  some 
hope  of  benefit.  But  when  once  the  stage  is  reached  where  weight 
is  progressively  lost,  and  where  relative  pyloric  obstruction  is 
present  (either  from  kinking  or  from  relative  stenosis  of  this  orifice 
of  the  stomach),  then  purely  medical   measures  no   longer  will   be 


i6o       Benign  Diseases  of  the  Stomach  and  Duodenum. 

found  efficient.  It  is  rarely  possible  by  medical  means  even  to 
keep  the  patient  from  losing  more  ground,  let  alone  improving 
him.  In  such  cases  as  these  we  think  operation  should  be  under- 
taken, provided  no  contraindication  to  any  operation  exists;  but 
the  patient  must  not  be  led  to  expect  an  immediate  cure.  Probably 
the  most  that  surgery  can  do  is  to  so  alter  the  mechanics  of  the 
stomach  and  intestines  that  medical  measures  will  become  effective. 
Hence  it  is  to  be  anticipated  that  a  prolonged  course  of  medical 
treatment  will  have  to  be  carried  out  after  the  operation  has  been 
performed. 

As  to  the  special  form  of  operation  to  be  employed,  it  is  at 
present  the  consensus  of  opinion  that  gastro-jejunostomy  is  the 
best.  We  rather  suspect,  however,  that  before  many  years  are 
past,  surgeons  will  more  generally  adopt  Finney's  pyloroplasty 
either  alone,  or  combined  with  some  form  of  gastroplication.  It 
is  difficult  to  decide  upon  the  respective  merits  of  these  two  methods, 
because,  as  already  remarked,  we  do  not  anticipate  the  phenom- 
enally rapid  amelioration  of  symptoms  after  operation  for  this  condi- 
tion that  we  do  in  cases  of  pyloric  obstruction  without  marked  atony; 
and  loo  many  medical  men  are  inclined  to  give  credit  for  the 
slowly  acquired  improvement  solely  to  the  medical  treatment  em- 
ployed, when  there  can  be  no  doubt,  at  least  so  it  seems  to  us, 
that  without  the  operation  which  improved  the  receptivity  of  the 
gastro-intestinal  tract,  food  and  drugs  would  have  been  of  as  little 
avail  as  they  were  before  the  patient  was  brought  to  the  surgeon. 
Our  own  preference  at  present  in  such  cases  is  for  gastro-jejunos- 
tomy, because,  in  our  judgement,  as  we  have  already  pointed  out 
(p.  113),  Finney's  operation  should  be  limited  to  cases  in  which 
gastric  motility  is  preserved;  but  as  far  as  one  can  judge  of  the 
tide  of  surgical  opinion,  it  is  now  setting  in  in  favour  of  plastic 
operations  on  the  jndorus  for  these  patients,  and  1)ccoming  gradu- 
ally opposed  to  gastrojejunostomy  for  any  but  obstructive  cases. 


Secondary  Gastric  Dilatation.  i6i 

Secondary  Gastric  Dilatation. — In  dealing  with  this  con- 
dition the  surgeon  must  never  lose  sight  of  the  fact  that  it  is 
not  a  distinct  disease.  Ever  before  his  eyes  must  be  the  picture 
of  a  stomach  that  has  become  dilated  after  ineffectual  efforts 
to  overcome  an  obstruction  to  its  evacuation.  Only  in  this  way 
will  he  be  able  to  appreciate  the  seriousness  of  that  stage  of 
the  disease  at  which  his  unfortunate  patient  has  arrived.  Were 
medical  treatment  always  effectual  in  treating  the  disease,  even 
when  instituted  at  the  commencement  of  the  malady,  the  surgeon 
would  never  see  any  patients  with  gastric  dilatation.  It  is  the 
terminal  stage  of  a  serious  disease,  and  as  such  is  the  gravest  stage. 
The  patient  may  have  been  in  danger  from  hemorrhage  or  from 
threatened  perforation  at  earher  periods  of  his  malady;  but  in 
addition  to  these  dangers,  which,  though  perhaps  less  imminent, 
still  persist,  he  is  now  afflicted  with  the  most  serious  compHcation 
of  all,  save  that  of  carcinomatous  association.  And  gastric  dila- 
tation due  to  benign  obstruction  is  less  serious  than  gastric  carci- 
noma only  because  patients  with  the  former  disease  die  more  slowly 
than  do  those  with  cancer.  Without  surgical  rehef,  both  diseases 
are  equally  fatal,  and  irremediably  so.  Cancer  usually  kills  in  a. 
shorter  time,  but  death  in  benign  gastric  dilatation  is  quite  as  sure 
even  if  longer  delayed. 

Causes. — Although  gastric  dilatation  in  the  immense  majority 
of  cases  is  caused  either  by  carcinoma  or  by  ulceration  about  the 
pylorus,  yet  in  exceptional  instances  other  factors  are  operative, 
and  should  therefore  be  borne  in  mind.  It  is  well  to  remember, 
also,  that  changes  in  the  duodenum,  similar  to  those  occurring  at 
the  pylorus  itself,  are  not  unfrequently  productive  of  gastric  dila- 
tation. Especially  is  this  true  of  ulceration  and  cicatrization  above 
the  ampulla  of  Vater;  but  ulcers  even  below  this  site,  as  well  as 
other  affections  of  the  duodenum  similar  to  those  implicating  the 
pylorus,  may  also  cause  dilatation  of  the  stomach. 

Systematic  writers  are  in  the  habit  of  classifying  the  causes 
of  obstruction  here,  as  elsewhere  in  the  ahmentary  tract,  as  those 
from  changes  in  the  wall  of  the  pylorus,  those  within  the  lumen  of 
the    canal,    and    those    which    cause    obstruction    by   distortion   or 


162       Benign  Diseases  of  the  Stomach  and  Duodenum. 

pressure  from  without.  Among  the  changes  in  the  pyloric  wall  itself, 
the  developement  of  carcinoma  probably  holds  first  place  in  the 
production  of  gastric  dilatation.  It  will  be  more  fully  considered 
in  a  subsequent  chapter.  Next  to  carcinoma,  pyloric  obstruction,  and 
consequently  gastric  dilatation,  is  most  frequently  due  to  hyper- 
plastic or  cicatricial  changes  produced  by  benign  ulceration.  As 
will  be  presently  pointed  out,  a  temporary  pyloric  obstruction  may 
be  caused  by  hyperplastic  ulceration  at  the  pylorus,  and  later  in 
the  course  of  the  ulcer's  evolution  the  hyperplasia  may  subside,  and 
the  pylorus  again  become  patent  for  a  short  time.  At  this  stage 
the  symptoms  of  gastric  ulcer  may  temporarily  disappear,  and  the 
patient  may  consider  himself  cured.  At  a  later  date,  however, 
the  latent  ulcer  will  again  give  evidence  of  its  existence,  when  by 
its  cicatricial  contraction  the  pylorus  again  becomes  obstructed, 
this  time  permanently.  The  earlier  and  temporary  obstruction 
usually  does  not  cause  gastric  dilatation;  it  is  rather  productive 
of  increased  peristalsis,  with  hypertrophy  of  the  muscular  walls, 
and  is  frequently  accompanied  by  pylorospasm,  gastrospasm,  and 
peristaltic  unrest  of  the  stomach  (see  p.  143). 

Apart  from  these  two  changes — carcinomatous  and  ulcerative — 
there  are  few  others  taking  place  within  the  walls  of  the  gastro- 
duodenal  canal  which  are  ever  productive  of  secondary  dilatation 
of  the  stomach.  Yet  Moullin  has  called  particular  attention  to 
fibrosis  of  the  pylorus  without  evidence  of  past  or  present  ulceration, 
as  a  cause  of  stenosis;  and  similar  cases  have  come  under  Dr.  Dca- 
ver's  care  at  the  German  Hospital.  Causes  of  obstruction  acting 
from  within  the  gastro-duodenal  canal  arc  very  rarely  causes  of  gas- 
tric dilatation.  The  ])ylorus  may  l:>e  obstructed  by  foreign  bodies, 
or  by  hair  balls,  or  by  concretions  due  to  medicines  such  as  bismuth 
administered  in  large  quantities  or  over  long  periods  of  time;  but 
it  is  extremely  unusual  for  such  agents  to  cause  any  but  intermittent 
obstruction  of  the  p}']orus.  The  same  is  true  of  such  i)athological 
changes  as  gastric  pol)7JUS  (sec  p.  221),  and  hydatid  cysts  in  the 
region  of  the  pylorus.  Pylorospasm  may  be  the  only  evidences  of 
such  changes. 

I)Ut    the   agents  are  many  wliirli    from    without    tlic    alimentary 


Secondary  Gastric  Dilatation.  163 

canal  may  cause  gastric  dilatation  by  means  of  pyloric  or  duodenal 
obstruction.  Not  only  may  adhesions  act  in  this  manner,  but  a 
distended  gall  Madder,  or  a  large  biliary  or  pancreatic  calculus  may 
similarly  be  productive  of  dilatation  of  the  stomach.  Chronic 
pancreatitis,  and  cancer  of  the  head  of  the  pancreas  may  so  obstruct 
the  duodenum  as  to  cause  secondary  gastric  dilatation.  Enlarged 
glands  in  the  portal  fissure  of  the  liver,  or  along  the  common  bile- 
duct,  as  well  as  retroperitoneal  tumors,  aneurisms,  etc.,  may  all 
in  exceptional  cases  be  productive  of  secondary  gastric  dilatation. 
Moreover,  in  addition  to  such  causes,  the  displacements  of  the 
various  abdominal  organs  may  eventually  lead  to  the  same  result. 
The  influence  exerted  by  a  floating  kidney  is  somewhat  hypothet- 
ical in  this  respect;  but  there  is  good  evidence  for  believing  that 
displacements  of  the  liver  due  to  tight  lacing  or  other  causes  may 
be  productive  of  dilatation  of  the  stomach.  The  modus  operandi 
of  the  change  is  not  always  easy  to  detect;  but  it  probably  is 
either  by  directly  obstructing  the  pylorus,  or  by  first  producing 
gastroptosis,  which  in  turn  brings  about  a  kinking  of  the  pylorus. 
The  latter  explanation  is,  we  believe,  the  more  probable,  and  it  has 
been  our  habit  to  teach  that  the  proptosed  stomach  is  always  dilated. 
Such  at  least  has  been  our  experience  at  operation. 

Perigastric  adhesions — or  perigastritis,  as  the  condition  was 
called  when  it  was  considered  a  distinct  disease,  analogous  to  peri- 
typhlitis— are  due  to  a  variety  of  causes.  The  adhesions,  however, 
which  are  productive  of  gastric  dilatation  are  usually  to  be  traced 
to  affections  of  the  biliary  tract.  Indeed,  disease  of  the  biliary 
tract  is  in  many  instances  the  origin  of  the  whole  chain  of  gastric 
disorders.  This  connection  has  already  been  noted  (page  69). 
In  a  smaller  number  of  instances,  perigastric  adhesions  causing 
pyloric  obstruction  have  arisen  in  attacks  of  plastic  peritonitis  due 
to  gastric  ulcers  themselves;  and  in  exceptional  cases  are  due  to 
previous  attacks  of  peritonitis  from  other  causes.  A  glance  at  Figure 
2 1  (Andrews)  will  show  how  disabling  these  adhesions  may  become. 

Clinical  Pathology. — The  changes  occurring  in  the  pylorus 
and  the  stomach  in  this  disease  are  reflected  with  fair  accuracy 
in  the   symptoms  which   are   observed.     In   the  early  stages  of  gas- 


164       Benign  Diseases  of  the  Stomach  and  Duodenum. 

trie  ulceration  there  frequently  occurs  such  h}'perplastic  reaction 
as  to  cause  obstruction  of  the  pylorus,  if  not  to  produce  a  palpable 
tumor.  Such  inflammatory  masses  as  these,  producing  pyloric 
obstruction,  and    simulating  a    malignant    tumor,    have  on    several 


Fig.  21. — Perigastric  Adhesions,  Involving  G all-Bladder,  Colon,  and  Sig- 
moid Flexure. 
Thf  small  intestine  has  l)C('n  rut  away. 

occasions  (seep.  117)  led  surgeons  to  llic  ])crformancc  of  gastro- 
jejunostomy, in  the  expectation  that  the  ])aticnt  would  thus  obtain 
some  little  respite  from  imminent  death.  In  such  cases  great  has 
been  the  sur])risc  of  the  surgeon  iind  the  joy  of  the  ijalicnl  to  olxserve 
after  a  few  months  that  the  suspccU'cl  Uimor  h;is  melted  away,  as  it 


Secondary  Gastric  Dilatation.  165 

were,  the  relief  obtained  by  means  of  the  operation  enabling  nature 
to  produce  a  cure  of  the  disease.  If  no  operation  had  been  per- 
formed at  that  time,  one  of  three  courses  might  have  been  pursued 
by  the  disease.  The  jfirst  and  most  usual  course,  we  think,  would 
be  that  under  appropriate  medical  treatment  sufficient  rest  would 
have  been  obtained  by  the  inflamed  area  for  a  decrease  in  the 
obstruction  to  have  occurred,  with  a  subsidence  of  the  symptoms 
of  peristaltic  unrest  of  the  stomach.  This  would  be  only  a  tem- 
porary lull,  however,  whereas  after  a  gastro-jejunostomy  we  should 
have  reason  to  expect  a  cure.  The  second  course  might  have  been 
for  the  obstruction  to  persist  and  to  lead  without  delay  to  gastric 
dilatation;  while  the  third  course,  and  one  which  we  are  satisfied 
is  less  rare  than  that  just  mentioned,  would  be  for  the  hyperplastic 
area  to  undergo  malignant  change,  whether  or  not  a  temporary 
lull  occurred  in  the  evolution  of  the  disease  under  medical  treatment. 

If  the  obstruction  of  the  pylorus,  due  to  the  hyperplastic  pro- 
cess, decreased  under  medical  treatment,  the  symptoms  would 
naturally  abate,  and  the  patient,  and  the  physician  as  well,  would 
naturally  regard  the  disease  as  cured.  But  in  the  vast  majority 
of  such  cases  there  comes  a  time,  perhaps  months  or  even  years 
later,  when  the  gastric  ulcer  in  its  course  of  cicatrization  and  con- 
traction again  narrows  the  pyloric  orifice,  and  when  the  old  stomach 
symptoms  begin  afresh.  It  is  at  this  stage  of  the  disease  that 
secondary  dilatations  are  most  frequently  seen. 

When  due  attention  is  paid  to  the  various  causes  of  pyloric 
obstruction,  it  is  not  difficult  to  picture  the  course  which  the  disease 
will  pursue  in  each  individual  case.  As  a  rule,  a  temporary  gastric 
hypertrophy  occurs,  with  increased  peristalsis,  and  for  a  time  the 
obstacle  may  be  overcome.  Sooner  or  later,  however,  the  gastric 
walls  yield,  and  from  the  stage  of  compensation  that  of  stagnation 
is  reached,  and  this  finally  drifts  into  absolute  retention.  The 
downhill  course  is  most  rapid  in  malignant  pyloric  obstruction; 
but  with  judicious  medical  treatment  it  may,  in  patients  with 
benign  obstruction,  extend  over  a  period  of  years. 

Symptoms. — The  symptoms  of  secondary  dilatation  of  the 
stomach  are  usually  sufficiently  pronounced.     In  the  earlier  stages 


1 66       Benio-n  Diseases  of  the  Stomach  and  Duodenum, 


!? 


of  the  disease,  when  compensation  is  present,  or  even  later,  when 
stagnation  has  commenced,  the  symptoms  are  less  distinct;  but 
when  once  retention  has  developed,  there  is  slight  probabiKty  of 
making  a  wrong  diagnosis. 

The  subjective  symptoms  are  much  the  same  as  those  which 
have  already  been  described  under  atonic  dilatation  of  the  stomach. 
But  the  previous  clinical  history  of  the  patient  will  usually  throw 
much  light  upon  the  diagnosis.  Usually  the  patient  at  an  earHer 
date  has  presented  symptoms  of  gastric  or  duodenal  ulcer;  and 
possibly  there  has  occurred  a  lull  in  the  evolution  of  the  disease, 
when  the  ulcer  was  healing  or  had  actually  healed,  and  before  it 
had  contracted,  or  while  the  tone  of  the  gastric  walls  was  still  suf- 
ficient to  compensate  for  the  slight  obstruction  present.  After  this 
temporary  abeyance  of  symptoms,  there  will  gradually  be  developed 
the  sense  of  fullness  persisting  after  meals,  perhaps  even  to  the 
time  of  the  next  meal,  and  thus  leading  to  anorexia.  Because  fluids 
are  not  absorbed  from  the  stomach,  and  because  in  the  stages  of 
stagnation  and  retention  they  are  late  in  reaching  the  small  intes- 
tine, if  they  reach  it  at  all,  there  is  more  or  less  constant  thirst.  As 
the  dilatation  progresses,  and  as  stagnation  becomes  extreme,  the 
dilating  stomach  occasionally  makes  the  attempt  to  empty  itself 
by  the  act  of  vomiting.  Generally  it  is  an  ineffectual  attempt, 
some  of  the  stomach  contents  not  being  expelled;  but  this  partial 
evacuation  procures  an  intermission  in  the  nausea  for  a  couple 
of  days.  The  very  fact  that  ingestion  of  food  does  not  always 
provoke  emesis  shows  that  the  ulceration  has  passed  the  irritable 
stage;  and  the  copious  and  cumulative  vomiting  which  recurs 
every  second  or  third  or  fourth  day  is,  in  itself,  very  good  evidence 
that  the  stomach  is  dilated. 

To  these  usual  symptoms  should  be  added  one  less  usual,  but 
of  increasingly  frequent  occurrence  in  these  last  years,  when  the 
pathology  of  gastric  disorders  has  become  Ijclter  understood.  We 
refer  to  gastric  tetany,  which  may,  we  think,  be  most  appro])riately 
considered  as  a  symptom  of  dilatation  of  the  stomach.  It  is  a 
subject  which  has  received  special  attention  from  Mayo  Robson; 
indeed  one  can    scarcelv   avoid    the   conclusion,    at  which  we  have 


Secondary  Gastric  Dilatation.  167 

ourselves  arrived,  after  a  somewhat  extensive  study  of  the  literature, 
that  tetany  is  more  often  of  gastro-intestinal  origin  than  due  to  any 
other  cause.  It  is  needless  to  dwell  here  upon  its  symptoms,  as 
they  are  detailed  in  every  text  book  of  medicine,  nor  on  the  various 
theories  as  to  its  cause;  it  is  sufficient  for  the  surgeon  that  he  be 
cautioned  to  let  no  such  case  pass  from  surgical  into  medical  care 
until  he  has  positively  ascertained  that  the  affection  is  not  asso- 
ciated with,  even  if  not  immediately  caused  by,  gastric  dilatation. 
Auto-intoxication  without  intestinal  putrefaction  is  admittedly 
rare,  as  has  already  been  pointed  out  (p.  159).  But  the  frequent 
association  of  tetany  with  secondary  gastric  dilatation  is  too  patent 
to  be  overlooked ;  and  even  in  one  case  of  infantile  pyloric  stenosis, 
tetany  was  a  prominent  symptom  (p.  138).  McKendrick  asserts 
that  there  are  on  record  about  63  cases  of  tetany,  which  are  clearly 
due  to  gastric  dilatation. 

According  to  some  authorities.  Globus  Hystericus  is  frequently 
due  to  the  drag  on  the  oesophagus  exerted  by  a  dilated  or  proptosed 
stomach. 

The  objective  symptoms  are  even  more  characteristic  than 
are  the  subjective.  The  capacity  of  the  stomach  is  seen  to  be  in- 
creased, not  only  from  the  excessive  amount  of  matter  vomited, 
but  from  the  amount  of  fluid  that  may  be  introduced  through  the 
stomach  tube.  Dilatation  of  the  stomach  with  air  wdll  also  make 
its  great  size  apparent.  In  men  the  dilatation  is  more  horizontal, 
while  in  women  the  increase  in  size  is  chiefly  toward  the  pelvis. 
The  level  of  the  greater  curvature  is  practically  always  found  below 
the  umbilicus,  and  in  women  it  not  unfrequently  reaches  to  the 
symphysis  pubis.  The  dilatation  with  air  should  be  very  gradu- 
ally done  by  means  of  a  hand  bulb  attached  to  the  stomach  tube. 
The  stomach  should  meanwhile  be  lightly  percussed  and  the  sen- 
sations of  the  patient  should  be  the  infallible  guide  as  to  the  limit 
of  distention  to  be  produced.  While  in  cases  of  open  ulcer  we 
think  even  the  passage  of  a-  stomach  tube  should  be  avoided  in 
most  cases  on  account  of  the  possibility  of  exciting  hemorrhage  or 
producing  a  perforation,  in  secondary  dilatation  of  the  stomach 
we  think  no  damage   can  be   done,  provided  common   sense  is  ex- 


i68        Benign  Diseases  oi  the  Stomach  and  Duodenum. 

crcised  and  the  manipulations  are  carried  out  with  gentleness  and 
patience.  Hurry  should  be  avoided  above  all  things;  it  is  under 
such  circumstances  the  equivalent  of  violence.  The  use  of  a 
Seidlitz  powder,  its  separate  parts  administered  at  short  intervals 
one  after  the  other,  may  be  more  agreeable  in  anticipation  to  the 
patient,  but  it  is  a  dangerous  and  uncontrollable  remedy,  and  as 
such  should  be  avoided.  It  is  impossible  to  determine  before- 
hand either  the  force  of  the  effervescence  or  the  capacity  of 
the  stomach;  and  while  w^e  are  well  aware  that  this  means  of 
distention  has  been  employed  many  more  times  safely  than  with 
disaster  (see  p.  326),  yet  it  is  a  method  which  in  our  opinion  is 
barbaric  in  its  simphcity.  The  determination  of  the  outlines  of  the 
stomach  by  means  of  skiagraphy,  after  the  administration  of  an 
emulsion  of  bismuth,  has  met  with  a  fair  amount  of  success  in  the 
hands  of  various  practitioners.  The  method  has  been  employed 
also  in  gastroptosis,  and  allied  conditions  (Worden). 

The  examination  of  the  contents  of  the  stomach  reveals  the 
usual  fermentative  and  putrefactive  changes  of  gastric  retention. 
The  fluid  withdrawn  settles  into  three  layers — the  lowest  of  semi- 
solid matter,  the  middle  of  clear  or  slightly  cloudy  yellow  fluid, 
while  the  topmost  layer  is  extremely  frothy,  due  to  the  gas-pro- 
ducing ferments  and  micro-organisms. 

The  jceces  of  the  normal  individual  contain  from  4  to  6  ounces 
of  solid  matter  in  twenty-four  hours,  and  aljout  75  per  cent,  of 
water.  As  a  result  of  the  lessened  absorption  which  occurs  in 
gastric  dilatation,  the  amount  of  solids  decreases  to  one  and  a 
half  or  two  and  a  half  ounces,  and  the  proportion  of  water  falls 
as  low  as  40  or  even  30  per  cent. 

'Thcurine'is  also  much  diminished  in  quantity,  and  the  amount 
of  ura'a  and  chlorides  is  decreased. 

Diagnosis  and  Differential  Diagnosis. — As  has  already  been 
mentioned,  extreme  degrees  of  gastric  dilatation  are  seldom  mis- 
taken for  other  affections.  It  is  in  the  early  stages — those  of  com- 
pensation and  mild  stagnation  that  the  disease  is  most  frequently 
overlooked.  Su(  h  patients  are  classed  as  dyspeptics,  and  are 
treated  in  our  (lis]jcnsarics  for    chronic    gastritis;     the    diagnosis    is 


Secondary  Gastric  Dilatation.  169 

based  on  the  symptoms  alone,  without  any  attempt  being  made 
to  trace  the  evolution  of  the  disease  or  to  apply  to  it  the  principles 
of  physical  examination  of  the  secretions,  and  their  digestive  power 
— methods  of  study  which  are  nevertheless  constantly  employed  in 
studying  the  kidneys,  the  cardio-vascular  system,  and  the  lungs. 
It  is  in  these  early  stages  that  the  pathologist's  findings  from  exami- 
nation of  the  gastric  contents  may  give  the  first  clue  as  to  the  nature 
of  the  disease.  But  it  is  only  a  clue,  and  should  be  so  regarded. 
Were  these  chronic  dyspeptics  studied  with  the  care  their  sufferings 
merit,  the  dispensaries  of  our  hospitals  would  have  fewer  return 
visits,  but  more  patients  would  be  permanently  cured  of  their 
maladies  by  surgical  means,  before  their  strength  and  vitality  had 
ebbed  so  low  that  scarcely  with  forced  feeding  and  stimulation 
will  many  of  them  be  brought  to  the  condition  where  they  may  be 
considered  good  operative  risks. 

When  the  early  stages  of  gastric  dilatation  are  once  recognized, 
it  next  becomes  important  to  determine  the  cause  of  the  dilatation; 
for  as  we  have  already  seen,  there  exist  two  distinct  groups  of  gas- 
tric dilatation,  the  atonic  and  the  obstructive.  The  former  is 
rare,  and  it  is  our  belief  that  it  grows  rarer  every  year,  as  more 
patients  are  subjected  to  operation,  and  as  the  surgeon  is  given 
more  opportunities  to  show  that  the  disease  is  really  of  an  obstruc- 
tive nature. 

With  due  attention  to  the  previous  history  of  the  patient  and 
strict  inquiry  into  the  clinical  course  of  the  present  illness,  of  which 
illness  gastric  dilatation  is  a  stage,  it  will  in  most  instances  be  quite 
possible  to  draw  a  distinction  between  myasthenic  and  obstructive 
dilatation  of  the  stomach.  When  the  symptoms  of  gastric  dilata- 
tion appear  after  a  distinct  period  of  gastric  trouble,  w^hether  im- 
mediately or  remotely  preceding  the  present  symptoms,  obstruction 
is  almost  certainly  the  cause.  If  the  dilatation  has  developed 
rapidly,  in  the  course  of  a  few  weeks  or  months,  without  a  long 
history  of  preceding  gastric  indigestion,  especially  if  the  patient 
be  past  early  adult  life,  malignant  disease  is  probable.  "Wlien 
no  preceding  indigestion,  typical  of  gastric  or  duodenal  ulcer,  or 
of   biliary  infection,  has    annoyed   the   patient   over  a  long   period 


170        Benign  Diseases  of  the  Stomach  and  Duodenum. 

of  time — when,  in  sliort,  the  cHnical  history  is  negative — then  it  is 
rather  probable  we  have  to  do  with  a  case  of  myasthenic  dilatation. 
A  point  in  the  differentiation  of  obstructive  from  atonic  dilatation 
of  the  stomach,  on  which  much  stress  is  laid  by  Van  Valzah  and 
Nisbet,  is  that  in  the  former  variety  of  dilatation  solids  are  much 
more  obstructed  than  are  liquids;  and  on  this  account  toxa?mic 
symptoms  are  less  usual  than  in  atonic  dilatation,  in  which  latter 
affection  the  fermenting  stomach  contents  every  now  and  again  are 
discharged  into  the  intestinal  canal,  whence  they  may  be  absorbed. 
In  obstructive  dilatation  fluids  are  evacuated  rapidly  compared  to 
the  rate  of  evacuation  of  solids,  so  long  as  the  stages  of  compensa- 
tion and  stagnation  persist;  and  Van  Valzah  and  Nisbet  claim 
that  in  this  disease  (obstructive  dilatation)  if  a  pint  of  water  be 
given  when  the  stomach  is  empty,  it  will  be  evacuated  within  one 
hour  and  a  half,  or  long  before  the  atonic  (myasthenic)  stomach 
"ceases  to  splash  or  to  yield  water  upon  the  introduction  of  the 
tube."  Atonic  dilatation,  they  remark,  was  once  called  the  "dys- 
pepsia of  liquids." 

In  myasthenia  pain  and  vomiting  are  exceptional;  in  obstruc- 
tion pain  is  a  prominent  feature,  especially  when  perigastritis  exists, 
and  copious  vomiting  every  few  days  is  the  rule.  Finally,  myas- 
thenic dilatation  is  usually  considerably  relieved  within  a  reasonable 
time  by  medical  treatment,  while  the  obstructive  form  grows  pro- 
gressively worse,  even  when  such  treatment  is  instituted  in  the  early 
stages. 

Dilatation  of  the  stomach  must  not  be  confounded  with  a  simple 
large  stomach,  whether  it  be  congcnitally  of  an  al:)normally  large 
size,  or  due  to  long  continued  overfilling.  In  such  a  stomach  an 
attack  of  gastritis,  due  to  some  unusual  indiscretion  in  eating  or 
drinking,  may  simulate  for  a  time  gastric  dilatation.  But  the 
inflammation  in  such  cases  is  quickly  relieved  by  functional  rest 
and  medical  treatment,  wlu'ch  is  not  the  case  where  the  stomach 
is  dilated. 

Gaslroplosis  is  another  affection  which  may  cause  rather  vague 
symptoms  of  indigestion.  But  the  surgeon  who  is  acute  in  eliciting 
a  patient's  clinical   history  will   not  easily  be   misled   into  mistaking 


Secondary  Gastric  Dilatation.  171 

gastric  dilatation  for  gastroptosis  or  vice  versa.  Because  in  the 
case  of  obstructive  dilatation  it  is  exceedingly  rare  for  the  clinical 
history  to  be  negative;  while  in  uncomplicated  cases  of  gastro- 
ptosis it  is  the  rule.  In  uncomplicated  cases  of  gastroptosis,  we  say; 
for  it  has  been  our  experience  that  the  proptosed  stomach  is  always 
dilated,  unless  it  forms  a  part  of  a  general  visceroptosis. 

Prognosis. — In  secondary  gastric  dilatation  the  prognosis  is 
bad,  unless  the  mechanical  obstruction  be  relieved  by  mechanical 
means.  All  that  was  said  on  the  prognosis  of  gastric  ulcer  in 
general,  should  be  borne  in  mind  in  this  connection.  It  was  there 
(p.  100)  pointed  out  that  under  the  best  medical  treatment  the 
death-rate  from  gastric  ulcer  in  general  is  at  least  8  per  cent.,  with 
a  large  proportion  of  relapses;  but  that  after  timely  operation, 
all  but  from  two  to  five  per  cent,  of  the  patients  recover,  and  most 
of  them  remain  permanently  cured.  The  statistics  from  which  these 
conclusions  were  dra-wn  included  not  alone  cases  of  open  gastric  ulcer, 
but  those  cases  where  the  stomach  was  very  extensively  diseased — 
dilated,  distorted,  or  contracted  as  a  result  of  chronic  ulceration. 
We  possess,  unfortunately,  no  series  of  statistics  by  which  we 
can  compare  the  results  in  patients  with  gastric  dilatation  who 
have  been  treated  medically,  with  those  obtained  in  the  same  class 
of  patients  after  operation.  The  large  masses  of  statistics  hitherto 
published  include  all  stages  of  gastric  ulcer;  and  it  is  only  because 
gastric  dilatation  is  a  more  serious  affection  than  gastric  ulcer 
without  dilatation  that  conclusions  which  are  justly  drawn  from 
statistics  of  the  disease  in  general,  apply  with  greater  force  to  its 
more  serious  aspects.  But  in  the  case  of  gastric  tetany,  we  may 
speak  in  figures  with  some  authority.  This  affection  enjoys  a 
mortality  under  medical  treatment  of  from  70  to  80  per  cent.  Al- 
though few  operations  so  far  have  been  done  for  its  relief,  and 
though  the  mortality  is  severe,  yet  when  compared  to  the  figures 
just  given  it  is  low.  Cunningham  collected  8  operations  for  gas- 
tric tetany,  with  5  recoveries  and  3  deaths,  a  mortality  of  37.5 
per  cent.  To  these  McKendrick  has  recently  added  16  successful 
cases,  making  a  total  of  24  operations  with  only  3  deaths,  a  mor- 
tality of  only  12.5   per  cent.     In  the   three  fatal  cases  (reported  by 


172        Benign  Diseases  of  the  Stomach  and  Duodenum. 

Fleiner  (2  cases),  and  Gumprecht),  death  was  due  to  visceral  dis- 
ease, to  pneumonia,  and  to  peritonitis. 

But  it  must  also  be  remembered  that  where  a  mechanical  obsta- 
cle exists  to  the  evacuation  of  the  stomach  it  will  be  only  a  question 
of  time  until  the  patient  starves  to  death  even  under  the  most 
energetic  medical  treatment.  The  starvation  is  slow,  and  it  is 
barely  possible  that  the  patient  will  not  recognize  the  fact  that 
he  is  starving  to  death;  but  the  intelligent  onlooker,  be  he  physician 
or  layman,  appreciates  the  true  seriousness  of  the  patient's  condi- 
tion ;  and  it  is  no  longer  necessary  for  the  surgeon  to  urge  that  in 
such  cases  surger}^  affords  the  only  escape  from  death.  What 
the  surgeon  still  urges,  is  that  the  operation  shall  be  undertaken 
while  yet  there  is  sufficient  recuperative  power  left  in  the  body 
cells  of  the  wretched  patient.  Perhaps  the  day  will  come,  but  it 
has  not  yet  dawned,  when  the  surgeon  will  no  longer  need  to  urge 
even  this,  but  when  all  physicians  will,  as  at  the  present  time  the 
most  progressive  of  them  do,  invite  the  surgeon  to  see  their  stomach 
cases  with  them,  in  order  that  they  may  decide,  in  the  light  of  the 
knowledge  the  physician  can  shed  on  the  case,  not  only  whether 
an  operation  is  required,  but  also  at  what  period  of  the  disease 
it  had  best  be  undertaken.  We  have  no  hesitation  whate\'cr  in 
saying  that  when  obstructive  dilatation  of  the  stomach  is  once 
diagnosed,  all  delay  should  be  a\'oided,  and  surgery  should  at 
once  remedy  the  mechanical  defect  which  Nature  and  her  hand- 
maid Medicine  are  unable  to  remove. 

Treatment. — The  choice  of  operation  lies  between  gastro- 
jejunostomy, pylorectomy,  and  pyloroplasty.  Unless  a  justifi- 
able su.spicion  of  malignancy  is  entertained,  we  think  pylorectomy 
for  gastric  dilatation  is  to  be  condemned.  We  should  propose 
excision  only  in  an  extremely  small  number  of  these  cases.  We 
believe  that  gastro-jcjunostomy  will  continue  to  ii^lvc  in  the  future, 
as  it  has  in  the  past,  the  best  results;  and  that  Finney's  operation 
should  be  reserved  for  those  patients  in  whom  f^jastric  motility  is 
but  .slightly  impaired.  This  would  limit  its  a])plication  to  gastric 
dilatation  to  the  earliest  stages  of  the  disease.  It  is  certain,  more- 
over,   that    gastro-jcjunostomy  gives    more    immcfliately  gratifying 


Secondary  Gastric  Dilatation.  173 

results  in  patients  whose  pylorus  is  almost  impassable  even  to 
liquids;  and  that  in  the  earlier  stages  of  dilatation,  where  the  py- 
lorus is  still  slightly  patent,  gastro-jejunostomy  will  at  times  fail 
as  a  primary  procedure,  and  that  the  surgeon  may  sometimes  be 
forced  to  ligate  the  pylorus  as  a  secondary  operation. 

Exclusion  of  the  Pylorus,  first  employed  in  1895  by  von  Eisels- 
berg,  has  recently  been  advocated  by  Jonnesco.  The  operation  con- 
sists in  sectioning  the  stomach  in  the  prepyloric  portion,  closing  both 
ends,  and  performing  posterior  trans-mesocolic  gastro-jejunostomy. 
We  do  not  see  that  it  presents  any  advantages  over  simple  ligation  of 
the  pylorus,  though  we  agree  with  Jonnesco' s  statement  that  it  is  a 
better  operation  for  open  ulcer  than  pylorectomy.  Jonnesco  reports  9 
such  operations  done  during  1906  and  1907;  all  the  patients  re- 
covered from  the  operation,  but  one  died  on  the  eighth  day  from 
hemorrhage;  the  others  were  permanently  cured.  Von  Eiselsberg 
employed  exclusion  of  the  pylorus  4  times,  all  the  patients  recovering, 
but  one  dying  eight  months  later  from  hemorrhage;  the  other 
patients  were  much  improved. 

REFERENCES. 

Cunningham:   Annals  of  Surgery,  1904,  i,  527.     (Gastric  tetany.) 

Jonnesco:   Revue  de  Chir.,  1907,  xxxvi,  601. 

McKendrick:   Scottish  Med.  and   Surg.  Jour.,   1907,  xxi,  253.     (Gastric 

tetany.)   • 
Moullin:   Lancet,  1907,  i,  156. 
Paterson:  Lancet,  1906,  i,  495.     (Gastric  tetany.) 
Robson   and   Moynihan:  Diseases   of  the    Stomach,   New  York,  1904,  p. 

408.     (Gastric  tetany.) 
Van  Valzah  and  Nisbet:  Diseases  of  the  Stomach,  London,  1900,  p.  347. 
Worden:   Univ.  of  Penna.  Med.  Bull.,  1906,  xix,  122. 


174     Benign  Diseases  of  the  Stomach  and  Duodenum. 


GASTROPTOSIS. 


Gastroptosis,  a  condition  in  which  the  whole  stomach  is  displaced 
do^Tiward,  sometimes  requires  surgical  treatment.  The  causes  of 
the  affection  are  obscure.  Glenard,  in  1885,  drew  attention  to  general 
visceral  prolapse  involving,  besides  the  stomach,  the  intestines,  usually 

the  right  kidney,  and  sometimes 
the  liver  and  spleen  as  well.  To 
account  for  these  changes,  various 
theories,  none  of  them  very  satis- 
factory', have  been  advanced.  Only 
a  few  setiological  factors  seem  to  be 
susceptible  of  demonstration.  It  is 
a  condition  which  is  very  much 
more  frequent  in  females,  and  good 
reasons  exist  why  this  should  be  so. 
Apart  from  the  influence  of  the 
clothing  of  that  sex,  including  the 
use  of  corsets,  the  practice  of  tight 
lacing,  and  of  suspending  hea^7• 
skirts  from  the  waist  instead  of 
from  the  shoulders  or  hips,  there 
are  the  well  kno\^^l  influences  of 
pregnancy  and  repeated  childbirths 
in  relaxing  the  abdominal  walls  and 
weakening  the  pelvic  floor.  All 
these  mechanical  factors  tend  to 
allow  a  descent  of  the  structures  in  the  u[)pcr  al)domcn.  Sco- 
liosis, and  other  deformities  of  the  skeleton  which  reduce  the  area 
of  the  upper  abdominal  regions,  are  also  considered  by  some  to 
be  causes  of  gastroptosis.  Sudden  loss  of  flesh,  as  in  wasting 
diseases,    such  as    typhoifl    fever   and    severe  attacks  of  intlucnza,  is 


Fig.  22. 


-Various  Degrees  of  Gas- 
troptosis. 


Gastroptosis.  175 

thought,  and  sometimes  with  apparent  good  reason,  to  be  a  cause 
of  gastroptosis.  The  influence  which  a  dilated  stomach  exerts, 
both  by  its  weight  and  its  atony,  has  been  too  little  appreciated; 
and  when  once  gastroptosis  is  added  to  dilatation,  food  stagnation 
is  mechanically  favoured,  and  one  condition  continues  to  aggra- 
vate the  other. 

The  clinical  pathology  of  gastroptosis  is  of  some  importance. 
Kelling  divides  gastroptosis  into  three  groups:  (i)  WHiere  the 
greater  curvature  of  the  stomach  is  still  above  the  umbilicus;  (2) 
where  the  lesser  curvature  is  still  above,  though  the  greater  has 
descended  below  the  navel;  and  (3)  where  even  the  lesser  curvature 
has  passed  below  the  umbilicus.  The  stomach  is  usually  dilated; 
indeed  we  have  never  seen  a  patient  with  gastroptosis  without 
dilatation  of  the  stomach,  unless  the  gastroptosis  was  only  a  part 
of  a  general  splanchnoptosis.  Among  32  cases  of  gastroptosis 
studied  by  Worden  there  were  only  3  in  which  the  stomach  was 
not  dilated.  The  gastro-hepatic  and  gastro-phrenic  omenta  are 
stretched;  the  stomach  becomes  more  or  less  horizontal,  lying  in 
the  transverse  rather  than  in  the  longitudinal  axis  of  the  body; 
and  in  extreme  cases  the  pylorus  itself  descends,  dragging  the  first 
and  second  portions  of  the  duodenum  with  it.  The  transverse 
duodenum  is  usually  so  securely  fixed  that  its  position  does  not 
change,  but  sometimes  it  is  found  lower  than  normal,  crossing  the 
fourth,  or  fifth,  instead  of  the  third,  lumbar  vertebra.  These 
changes  naturally  are  prone  to  cause  a  kinking  of  the  pylorus, 
and  will  add  to  the  gastric  dilatation  usually  present.  A  floating 
kidney,  which  by  its  weight  displaces  the  duodenum  and  trans- 
verse colon,  is  a  well  recognized  factor  in  the  developement  of 
gastroptosis. 

The  symptoms  of  gastroptosis  are  occasionally  absent,  even 
when  the  displacement  is  well  marked.  In  other  patients  a  very 
slight  degree  of  gastroptosis  causes  very  distressing  and  disabling 
symptoms.  Those  of  neurasthenia  are  frequently  more  pronounced 
than  the  symptoms  referable  to  the  stomach  itself.  In  general 
the  symptoms  resemble  those  of  dilated  stomach.  There  is  flatu- 
lence  after    eating,  occasionally  so    pronounced    as    to    constitute 


176      Benign  Diseases  of  the  Stomach  and  Duodenum. 

peristaltic  unrest  of  the  stomach.  The  clothes  are  loosened  and 
in  severe  cases  the  reclining  position  is  habitually  assumed  after 
meals.  Large  meals  are  avoided ;  and  so  painful  may  the  process 
of  digestion  become  that  patients  will  almost  starve  themselves 
rather  than  endure  it.  Emaciation  is  the  usual  sequel.  The  pain 
is  a  tearing  or  a  stretching  sensation,  as  a  rule  easily  distinguishable 
from  the  intense  boring  pain  of  gastric  ulcer  or  cancer. 

From  symptoms  alone  it  is  rarely  possible  to  reach  an  accurate 
diagnosis.  Physical  examination  is  much  more  satisfactory. 
Inspection  of  the  abdomen,  with  the  patient  standing,  usually 
reveals  a  protruding  lower  abdomen,  not  due  to  fat,  for  these 
patients  are  usually  emaciated,  but  to  the  descent  of  the  stomach 
from  the  epigastric  to  the  umbilical  or  hypogastric  regions.  The 
epigastrium  is  empty  and  hollow,  and  frequently  the  pulsations 
of  the  aorta  are  visible  below  the  ensiform  process.  On  palpation 
this  pulsation  can  almost  always  be  felt  with  abnormal  distinctness. 
The  contour  of  the  lower  chest,  showing  the  effects  of  corset  pres- 
sure, is  of  diagnostic  value.  Some  authors  have  insisted  upon 
the  mobility  of  the  tenth  rib,  as  a  predisposing  cause,  allowing 
undue  pressure  upon  the  liver,  and  through  it  displacing  the  sto- 
mach. Palpation  and  percussion,  especially  when  the  stomach 
has  been  distended  with  air  or  fluid,  will  readily  enable  the  examiner 
to  outline  the  greater  curvature,  and  in  severe  cases  the  lesser 
curvature  also  may  be  detected  in  this  manner.  Skiagraphy, 
with  the  aid  of  emulsions  of  bismuth,  has  been  evoked  by  certain 
authors  in  the  study  and  diagnosis  of  displacements  of  the  stomach 
(Wordcn,  Pfahler,  Sailer,  Pancoa'st).  By  its  aid  much  of  interest 
may  be  learned,  though  we  incline  to  the  opinion  that  a  correct 
diagnosis  may  almost  always  be  made  without  it. 

Surgical  treatment  is  rarely  called  for  in  cases  of  simj)le  gastrop- 
tosis.  When  successful,  it  is  ratlicr  Ix'causc  the  stomach  was  dilated, 
and  because  by  operation  its  motility  is  improved,  than  Ijecause  the 
malposition  is  corrected. 

Gasiroplication,  proposed  as  a  remedy  for  dilated  stomach  in 
1S91  by  Bircher,  was  first  employed  by  Summers  in  1897  in  a  case 
of  gastroptosis. 


Gastroptosis.  177 

Duret,  in  1896,  was  the  first  to  resort  to  operation  for  the  rehef 
of  gastroptosis.  He  did  a  gastropexy,  suturing  the  anterior  gastric 
wall  to  the  parietal  peritoneum.  Rovsing  and  Hartmann  employed 
similar  operations.  A  second  method  of  operating  by  gastropexy 
was  practised  in  1897  by  Beyea,  who  shortened  the  gastro-hepatic 
omentum  by  a  series  of  interrupted  sutures.  About  the  same  time 
Bier  devised  and  employed  a  similar  operation,  though  an  account 
of  his  method  was  not  published  until  later.  Coffey  sutured  the 
root  of  the  great  omentum  to  the  abdominal  wall,  thus  giving 
support  to  the  stomach  from  below.  Rovsing,  Kammerer  and 
others  surgeons  have  employed  gastro-jejunosiomy. 

Our  own  preference  has  always  been  for  gastro-jejunostomy, 
and  for  the  reason  already  given,  that  we  have  never  yet  seen  a 
case  of  simple  gastroptosis  in  which  gastrectasis  was  not  also  pres- 
ent. The  relief  of  symptoms,  in  the  patients  on  w^hom  w^e  have 
operated  for  gastroptosis,  while  gratifying,  has  not  of  course  been 
so  pronounced  or  so  constant  as  in  patients  with  dilatation  of  the 
stomach  without  gastroptosis.  Many  surgeons  share  in  this  pref- 
erence for  gastro-jejunostomy.  Hammer,  both  from  a  review  of  the 
literature  and  from  his  personal  experience,  prefers  gastro-jejunos- 
tomy to  any  other  form  of  operation. 

The  objections  to  gastropexy  by  Buret's  method  are  the  inter- 
ference with  the  motility  of  the  stomach  and  the  liability  of  the 
newly  formed  adhesions  to  cause  more  discomfort  than  the  original 
disease.  From  these  particular  objections  the  method  of  Beyea 
is  free,  since  the  stomach  is  raised  to  approximately  its  normal 
position  by  shortening  the  gastro-hepatic  omentum,  without  the 
formation  of  adhesions  to  the  stomach  itself.  Beyea  has  recently 
stated  that  he  has  resorted  to  this  operation  in  eight  patients,  all 
of  whom  were  permanently  benefitted  by  the  procedure,  except 
one,  who  suffered  a  return  of  symptoms  after  being  overworked. 
E.  B.  Hodge,  Jr.,  in  one  case  successfully  combined  Beyea's 
operation  with  gastroplication.  Yet  in  not  a  few  patients  return 
of  symptoms  after  such  procedures  has  necessitated  a  final  resort 
to  gastro-jejunostomy.  The  possibility  of  puncturing  blood-vessels 
in  the  gastro-hepatic  omentum  has  so  far  restrained  us  from  adopting 


1/8       Benign  Diseases  of  the  Stomach  and  Duodenum. 

this  operation  of  Dr.  Beyea's.  Although  we  are  not  aware  that  any 
evil  results  have  followed  its  performance,  yet  as  gastro-jejunostomy 
has  corrimended  itself  to  us  in  both  theory  and  practice,  we  feel  con- 
strained to  advise  its  adoption  rather  than  Beyea's  operation,  in  case 
anv  operation  should  be  determined  upon.  Many  patients,  more- 
over, with  gastroptosis  have  the  gastro-hepatic  omentum  so  attenuated 
bv  the  duration  of  the  disease  and  the  weight  of  the  stomach,  that 
sutures  would  be  very  likely  to  tear  loose.  Should  Beyea's  opera- 
tion be  employed,  the  horizontal  position  should  be  maintained 
for  at  least  three  weeks. 

Finally  it  may  be  well  to  insist  again  upon  the  impropriety 
of  performing  any  operation  in  the  majority  of  cases  of  gastro- 
ptosis. ^luch  comfort,  indeed  an  almost  complete  relief  from 
invalidism,  may  frequently  be  obtained  by  the  use  of  a  well  fitting 
abdominal  binder.  An  ill  fitting  belt  is  worse  than  useless.  But 
where  the  neurotic  svmptoms  are  not  excessive,  and  where  consti- 
pation is  extremely  intractable,  an  emaciated  wreck  may  sometimes 
be  restored  to  a  useful  life  by  the  simple  operation  of  gastro-jejun- 
ostomy. 

REFERENCES. 

Beyea:   Trans.  Coll.  Phys.  Phila.,  1899,  xxi,  76. 

Beyea:  Annals  of  Surgery,  1906,  i,  776. 

Bier:   See  Blecher,  Deutsch.  Zeit.  f.  Chir.,  1900,  Ixi,  374. 

Bircher:   Corr.-Bl.  f.  Schweizer  Aerzte,  1891,  xxi,  713. 

Cofifey:   Phila.  Med.  Jour.,  1902,  x,  506. 

Duret:  Revue  de  Chir.,  1896,  xvi,  421. 

Hammer:   Munch,  med.  Woch.,  1903,  ii,  2102. 

Hartmann:   Bull,  et  Mem.  Soc.  Chir.  Paris,  1899,  xxv,  443. 

Hodge:   Annals  of  Surgery,  1906,  i,  775. 

Kammerer:  Annals  of  Surgery,  1901,  ii,  302. 

Pancoast:  Trans.  Coll.  Phys.  Phila.,  1906,  xxviii,  177. 

Sailer:  Trans.  Coll.  Phys.  Phila.,  1906,  x.xviii,  168. 

Summers:   Kansas  City  Med.  Index,  1897,  xviii,  181. 

Worden:   Trans.  Coll.  Phys.  Phila.,  1906,  xxviii,  151. 


CHAPTER  VI. 

BENIGN    DISEASES    OF  THE  STOMACH  AND  DUODENUM 

(Continued). 

OBSTRUCTION  OE  THE  CARDIAC  ORIFICE  OF  THE 
STOMACH. 

Congenital  Imperforation  of  the  (Esophagus. — ^Although  this 
affection  is  extremely  rare,  and  is  seen  rather  by  the  ptediatrist 
than  the  general  surgeon,  yet  it  seems  worthy  of  short  notice  in  this 
chapter,  inasmuch  as  gastrostomy  or  some  similar  operation  pre- 
sents the  only  hope  of  cure. 

The  subject  has  been  well  reviewed  by  Demoulin,  who  suc- 
ceeded in  collecting  fifty  recorded  cases.  The  gastric  portion  of 
the  cesophagus  communicated  with  the  trachea  in  44  of  these  cases, 
and  with  the  bronchi  in  2  cases.  It  is  therefore  extremely  unusual 
for  the  malformation  to  consist  of  a  simple  obstruction  of  the 
lumen  of  the  oesophagus  by  a  membrane,  or  even  for  the  two  por- 
tions of  the  oesophagus  to  lie  in  the  same  axis,  connected  by  a 
fibrous  band.  The  symptoms,  which  exist  from  the  time  the  child 
begins  to  take  nourishment,  consist  first  in  the  constant  and  per- 
sistent regurgitation  of  food,  and  second  in  the  recurrent  attacks  of 
smothering  which  are  recognized  as  characteristic  of  the  disease. 
These  smotherings  are  due  to  the  regurgitation  of  mucus  and 
gastric  juice  into  the  air  passages,  through  the  gastric  portion  of 
the  oesophagus.  If  the  baby  does  not  die  of  asphyxia  in  one  of 
these  attacks,  .pneumonia  may  occur  from  the  regurgitation  of 
gastric  fluids,  or  from  the  inspiration  of  food.  Inanition  will 
quickly  kill  the  infant  should  he  escape  other  perils. 

Operative  treatment,  according  to  Demoulin,  was  first  sug- 
gested in  1866  by  Tarnier,  who  proposed  gastrostomy.  Steel  (1888) 
was  the  first  to  perform  gastrostomy.  His  patient  was  twenty- 
four  hours   old,  and  died  in  twenty-four  hours.     In  1903  Robineau 

179 


i8o       Benign  Diseases  of  the  Stomach  and  Duodenum. 

again  operated,  on  the  third  day  of  life,  by  gastrostomy;  but  his 
patient  died  on  the  third  day.  Villemin's  case,  reported  by  Demoulin, 
was  operated  on  in  1904,  at  the  age  of  three  days,  by  gastros- 
tomy; this  patient  lived  five  days  after  the  operation.  Kirmisson 
reported  the  fourth  fatal  case,  operated  on  at  the  age  of  three  days 
bv  gastrostomv.  Putnam  has  added  a  fifth  fatal  case.  Bau- 
douin  says  that  Veillard  and  Le  Mee  found,  in  1906,  six  fatal  gas- 
trostomies recorded  for  this  affection. 

The  question  naturally  arises,  in  view  of  the  extent  of  the  mal- 
formation, whether  any  operation  can  be  expected  to  be  of  benefit. 
Broca  has  expressed  himself  as  unalterably  opposed  to  any  opera- 
tion on  an  infant  so  malformed. 

In  discussing  Demoulin's  paper,  Broca  gave  as  his  opinion 
that  death  is  the  best  solution  of  the  difficulty;  that  he  had  been 
gratified  to  learn  that  all  the  patients  operated  on  had  died;  and 
that  on  this  account  he  was  glad  to  study  with  Demoulin  new  and 
more  complicated  operations,  because  these  will  be  still  more  certain 
to  result  in  death.  Never,  he  said  in  conclusion,  would  he  assume 
the  responsibility  of  putting  into  circulation  in  the  world  an  infant 
with  its  mouth  in  the  duodenum!  To  our  mind,  such  an  infant 
is  no  more  of  a  monstrosity  than  one  whose  alimentary  tract  emp- 
ties into  the  bladder,  or  possesses  no  opening  at  all  at  its  lower 
extremity;  and  we  fail  to  see  why,  if  operation  be  justifiable  in  one 
case,  it  will  not  be  equally  so  in  the  other.  The  surgeon  is  not 
an  executioner.  It  is  not  for  him  to  decide  whether  an  individual 
is  fit  to  live  or  not.  His  duty  is  to  prolong  his  patient's  life,  and 
to  use  the  agencies  of  modern  surgery  in  the  attempt  to  overcome 
deformities  and  to  restore  the  malformed  to  a  state  as  nearly  normal 
as  po.ssible.  It  may  be  objected  to  this  reasoning  that  a  patient 
who  already  has  a  malformation  of  his  crsophagus  is  rendered  only 
more  abnormal  by  the  formation  of  a  gastric  fistula.  Such  a  reply, 
we  submit,  is  not  argument,  it  is  repartee.  But  it  may  be  further 
argued,  that  even  were  the  patient  who  has  submitted  to  gastros- 
tomy to  .survive  the  perils  of  infancy — that  even  were  he  to  reach 
an  age  when  a  more  serious  operation  might  justifiably  be  under- 
taken— it  might  be  said  that  even  at  that  jx-riod  of  his  life  surgery 


Congenital  Imperforation  of  the  CEsophagus.  i8i 

could  offer  no  permanent  solution  of  the  difficulty;  in  other  words 
that  the  restoration  of  an  oesophagus  whose  upper  end  is  a  blind 
pouch,  and  whose  lower  end  opens  into  the  trachea,  is  a  problem 
beyond  the  possibility  of  solution  by  surgery.  For  our  own  part, 
we  do  not  take  so  narrow  a  view  of  the  surgical  fjossibilities  of  the 
future.  We  have,  on  the  contrary,  the  utmost  confidence  that 
all  problems  of  mere  technique  will  ultimately  be  solved.  We 
cannot,  of  course,  hope  to  make  a  new  oesophagus  grow;  but  given 
the  patient,  fit  for  an  operation  for  the  restoration  of  such  an  oesoph- 
agus, and  we  doubt  not  that  some  surgeon  will  solve  the  prob- 
lem of  the  technique.  It  may  not  be  in  Broca's  time,  nor  even 
during  our  own  lives ;  but  we  are  none  the  less  confident  that  such 
a  time  will  come.*  The  surgery  of  the  chest  is  younger  even  than 
the  surgery  of  the  stomach,  which  is  about  the  youngest  thing  in 
surgery  today;  and  though  Sauerbruch's  air  chamber  may  not  solve 
all  the  problems  of  intrathoracic  operations,  we  are  nearer  by 
many  steps  to  the  goal  than  even  ten  years  ago.  We  therefore 
give  it  as  our  unqualified  opinion  that,  save  in  the  already  mori- 
bund, the  surgeon  is  not  only  justified  in  resorting  to  operation,  but 
he  would  be  worthy  of  condemnation  should  he  refuse  to  employ 
the  skill  he  possesses  in  the  attempt  to  give  these  patients  a  fighting 
chance  for  life. 

Gastrostomy  has  heretofore  been  the  only  operation  employed. 
On  account  of  the  danger  of  liquids,  injected  into  the  stomach 
by  the  gastric  fistula,  entering  the  lungs  by  way  of  the  oesophageal 
communication,  Demoulin  suggested  that  jejunostomy  would  be  a 
safer  operation.  If  this  could  be  safely  combined  with  ligation  of 
the  pylorus,  and  gastrostomy  as  well,  a  state  of  affairs  temporarily 
satisfactory  might  be  obtained.  If  the  pylorus  were  not  li gated, 
bile  and  pancreatic  juice,  and  possibly  also  the  injected  food  stuffs, 

*  The  above  paragraphs  were  written  before  the  publication  (January,  1907)  of 
the  daring  operation  by  which  Roux  of  Lausanne  seeks  to  form  a  new  oesophagus  by 
transplanting  beneath  the  skin  of  the  sternum  a  coil  of  the  jejunum  excluded  from 
the  intestinal  tract;  and  also  before  the  appearance  of  Baudouin's  article,  referred 
to  above,  where,  being  ignorant  of  Roux's  operation,  he  proposed  to  connect  an  oesoph- 
agostomy  opening  in  the  neck,  vidth  a  gastrostomy  opening  in  the  epigastrium,  by 
means  of  a  rubber  tube,  or  some  similar  contrivance.     (See  page  359.) 


1 82     Benign  Diseases  of  the  Stomach  and  Duodenum. 

might  find  their  way  into  the  stomach;  and  unless  the  stomach, 
even  when  excluded  from  the  digestive  tract,  as  by  ligation  of  the 
pylorus,  were  drained  exteriorly,  it  would  still  discharge  its  secre- 
tions into  the  trachea,  and  so  threaten  death  from  suffocation. 
Possibly  gastro-jejunostomy  combined  with  gastrostomy,  by  the 
method  of  Rutkowski  and  Witzel,  might  accomplish  the  same 
result.  But  any  operation  on  infants  a  day  or  so  of  age  must  be 
simple  and  quick;  and  for  these  reasons  we  prefer  gastrostomy. 
Roux's  method  of  subcutaneous  gastro-cesophageal  anastomosis 
(p.  358)  will  afford  the  patient  a  chance  for  ultimate  cure,  should 
immediate  death  be  averted. 

REFERENCES. 

Baudouin:  Ann.  Internat.  de  Chir.  Gastro-Intest.,  1907,  i,  124, 

Broca:  Bull,  et  Mem.  Soc.  Chir.  Paris,  1904,  xxx,  735. 

Demoulin:  Bull,  et  Mem.  Soc.  Chir.  Paris,  1904,  xxx,  730. 

Kirmisson:  Bull,  et  Mem.  Soc.  Chir.  Paris,  1904,  xxx,  745. 

Putnam:   Surg.  Gyn.  and  Obstetr.,  1906,  ii,  603. 

Rutkowski  and  Witzel:    See  Moynihan's   Abdominal   Operations,   Phila. 

and  London,  1905,  p.  141. 
Steel:  Lancet,  1888,  ii,  764. 
Veillard  and  LeMee:    Revue    des    Malad.  de  I'Enfance,  1906,  Dec,  p. 

554,  cited  by  Baudouin,  loc.  supra  cit. 


Cardiospasm.  183 

Cardiospasm. — Cardiospasm,  an  affection  not  of  excessive  rarity, 
is  analogous  to  pylorospasm  and  gastrospasm.  Gottstein  refers  to  145 
cases,  of  which  25  came  under  his  own  care.  Its  pathology  is  obscure, 
but  is  probably  much  the  same  as  that  of  the  affections  men- 
tioned. A  polyp  was  the  cause  in  the  case  reported  by  Led- 
derhose.  Mild  cases  probably  often  pass  unperceived.  The  pa- 
tient, usually  a  w^oman,  from  thirty  to  forty  years  of  age,  may 
feel  that  the  food  lodges  a  moment  before  entering  the  stomach; 
and  the  individual  affected  may  be  able  to  force  it  through  volun- 
tarily, by  taking  a  long  breath  and  contracting  certain  of  the  pharyn- 
geal and  oesophageal  muscles.  In  more  severe  cases  a  pouch  may 
develope,  and  the  patient,  eating  little  at  a  time,  will  form  a  habit 
of  retiring  to  a  quiet  nook  after  taking  food,  and  will  there  wrestle 
with  the  obstruction  until  it  either  gives  way,  or  the  distress  oc- 
casioned is  relieved  by  vomiting.  The  bougie  in  such  cases  will 
usually  detect  both  the  obstruction  and  the  pouch.  The  diagnosis 
from  cancer  is  best  made  by  the  symptoms :  pain  and  hemorrhage 
being  the  most  prominent  symptoms  of  malignant  disease  of  the 
cardia,  while  in  cardiospasm  pain  is  never  severe,  and  hemorrhage 
is  of  the  utmost  rarity.  Should  the  periodical  passage  of  a  bougie 
fail  to  relieve  the  condition,  much  may  be  hoped  for  from  operation. 
But  as  the  latter  form  of  treatment  is  not  free  from  risk,  medical 
measures  and  the  passage  of  bougies  should  be  persisted  in  until 
there  can  be  no  doubt  of  their  failure  to  relieve  the  affection. 

Rosenheim  employed  balloon  dilators,  introduced  through  the 
oesophagus,  in  the  treatment  of  this  affection,  and  with  a  fair  meas- 
ure of  success.  One  patient  reported  remained  well  for  over  two 
years.  This  method  had  been  adopted  formerly  by  Russell,  and 
recently  has  been  commended  by  Plummer,  who  employed  it  in  36 
patients.  The  operation  of  divulsion  of  the  cardia  for  cardiospasm  is  said 
by  the  late  Prof.  Ashhurst  to  have  been  employed  by  Loreta,  v.  Berg- 
mann,  Catani,  Frattini,  and  Billroth.  Mikulicz  reported  four  patients 
as  having  been  cured  by  the  procedure.  These  cases  were  reported  at 
intervals,  respectively  of  12,  6,  2,  and  i  month  after  the  operation,  no 
recurrence  of  the  trouble  being  noted  in  any  case.  Two  later  opera- 
tions by  Mikulicz  also  resulted  in  cure  (Gottstein).     Ledderhose's 


184       Benign  Diseases  of  the  Stomach  and  Duodenum. 

patient,  already  referred  to,  recovered,  after  the  removal  of  a  polyp 
from  the  lower  end  of  the  oesophagus.  Erdman  and  Martin  have 
each  reported  a  successful  case  of  divulsion  of  the  cardia,  the  opera- 
tion having  been  performed  twenty  months  and  six  months,  respec- 
tivelv,  before  the  reports  were  made.  In  a  patient  of  W.  J.  Mayo's, 
mentioned  by  Plummer,  relief  for  four  months  was  obtained  by  divul- 
sion of  the  cardia  after  gastrotomy. 

After  opening  the  stomach  through  its  anterior  wall  the  cardiac 
orifice  is  divulsed  digitally  (Mikulicz  employed  forceps  with  rubber 
covered  blades)  until  two  or  even  three  fingers  will  readily  enter 
the  oesophagus.  The  stomach  is  then  closed,  replaced,  and  the 
abdominal  wound  repaired  without  drainage. 

REFERENCES. 

Ashhurst:   Principles  and  Practice  of  Surgery,  Phila.,  1893,  6th  Ed.,  p. 

968. 
Erdman:   Amials  of  Surgery,  1906,  i,  224. 
Gottstein:   Keen's  Surgery,  Phila.,  1908,  iii,  802. 
Ledderhose:    Deutsch.    mad.    Woch.,    1904,    xxx,    1669;    Munch,    med. 

Woch.,  1904,  i,  1 1 79. 
Martin:   Penna.  Med.  Jour.,  1906,  ix,  336. 
Mikulicz:   Deutsch.  med.  Woch.,  1904,  i,  17;   50. 
Plummer:   Jour.  Amer.  Med.  Assoc,  1908,  ii,  549, 
Rosenheim:   Berl.  klin.  Woch.,  1902,  xxxix,  288. 
Russell:    Brit.  Med.  Jour.,  1898,  i,  1450. 


Obstruction  of  the  Cardia.  185 

Cicatricial  Contraction  of  the  Cardiac  Orifice  of  the 
Stomach,  from  other  than  malignant  disease,  is  so  extremely 
rare  that  it  need  only  be  mentioned  in  passing.  When,  as  is  less 
unfrequently  the  case,  it  is  caused  by  the  ingestion  of  corrosive 
liquids,  the  symptoms  are  overshadowed  by  those  of  oesophageal 
stricture,  but  when  this  tube  is  not  involved,  the  usual  symptoms 
of  cardiac  obstruction  are  present,  but  without  the  cachexia 
which  so  early  developes  in  cancer.  If  bougies  fail  to  keep 
the  passage  open,  gastrostomy  may  be  done,  and  the  cardia  may 
be  cautiously  dilated  instrumentally  or  by  the  fingers,  and  ret- 
rograde passage  of  a  bougie  attempted.  Much  good  may  ensue, 
as  in  stricture  of  the  oesophagus,  from  attaching  a  string  to  the 
bougie,  and  drawing  it  out  of  the  mouth.  The  stricture  may  then 
be  sawed  by  means  of  the  string,  whose  two  ends,  passing  from  the 
mouth  and  the  gastrostomy  wound,  may  be  tied  together  and  thus 
kept  safely  in  place.  Or  gradually  increasing  sizes  of  rubber  tub- 
ing may  be  drawn  through  the  stricture  by  means  of  the  string. 
It  is  well  in  any  case  to  keep  the  gastric  fistula  patulous  for  a  number 
of  months;  it  may  be  used  from  time  to  time  while  some  passing 
irritation  of  the  cardia  is  subsiding,  and  until  nourishment  may 
be  taken  again  in  the  usual  way.  Mayo  Robson  refers  to  two 
patients  of  his  living  some  years  after  a  gastrostomy  performed 
under  these  conditions,  and  he  states  that  they  still  occasionally 
make  use  of  the  gastric  fistula,  and  find  no  inconvenience  in  its 
existence. 

REFERENCE. 

Robson:  First  Congress  of  the  International  Society  of  Surgery,  Brussels, 
1906.     Reprint. 


CHAPTER  VII. 

HOUR-GLASS  STOMACH  AND  GASTRIC  DIVERTICULA.' 

Hour-glass  Stomach. — This  term  well  describes  the  condition 
found  in  the  immense  majority  of  patients  in  whom  the  stomach 
is  loculated;  but  as  cases  are  occasionally  observed  in  which  three 
(Moynihan,  Paterson,  Kausch,  Schmitt)  and  even  five  pouches 
(Klein)  exist,  the  term  segmented  stomach,  advocated  by  Wolfler, 
is  more  generally  applicable.  And  as  diverticula  of  the  stomach  are 
produced  by  essentially  the  same  causes  as  those  operative  in  cases 
of  hour-glass  contraction,  it  is  convenient  to  consider  them  both  in 
the  same  chapter. 

The  condition,  first  noted  by  Amyand,  was  subsequently  de- 
scribed by  Morgagni.  The  earlier  writers  on  the  subject,  and 
those  even  until  recent  years,  considered  it  a  congenital  anomaly 
in  the  vast  majority  of  cases.  Later  writers,  notably  Moynihan, 
have  proved  that  as  a  congenital  deformity  it  is  of  the  utmost  rarity, 
if  indeed  not  altogether  unknown.  Moynihan  is  not  willing  to 
accept  as  genuine  examples  of  congenital  deformity  any  of  the 
cases  whose  records  he  has  examined,  nor  has  his  study  of  museum 
specimens  altered  his  opinion.  Delamare  and  Diculafe  have 
recently  recorded  the  case  of  a  bilocular  stomach  in  a  new  born 
baby,  born  of  syphilitic  parents,  but  with  no  syphilitic  lesions 
itself;  in  this  case  the  only  lesion  found,  even  on  microsco])ical 
examination,  consisted  in  hypertrophy  of  the  muscular  coat  at 
the  junction  of  the  cardiac  and  the  pre-pyloric  portions.  Gardiner 
observed  hour-glass  contraction  of  the  stomach,  associated  with 
a,n  accessory  pancreas,  ill 'dutoi)Hy  on  a  child  of  three  months  old.  It 
must  further  be  remarked  that  as  recent  anatomo-physiological 
researches  have  called  renewed  attention  to  the  stomach,  we  realize 
the  truthfulness,  heretofore  almost  forgotten,  of  the  descriptions 
of  normal  stomachs  long  ago  made  by  Home,  Cruvcilhier,  Henle, 

i86 


Hour-glass  Stomach.  187 

and  others;  and  we  are  thus  able  to  explain  as  normal  many  ap- 
pearances found  post-mortem  which  were  at  one  time  considered 
pathological  (See  Chap.  II,  p.  47).  Moreover,  even  in  cases  of 
hour-glass  stomach  observed  in  infants  and  young  children,  it 
may  be  quite  possible  for  the  deformity  to  be  explained  as  due 
to  pre-existent  disease  of  the  stomach  in  infantile  or  intrauterine 
life. 

While,  therefore,  it  cannot  be  categorically  denied  that  such  a 
thing  as  a  congenital  hour-glass  stomach  may  occur,  it  mmst  be 
acknowledged  to  be  of  extreme  rarity;  and  any  cases  reported  as 
such  deserve  prolonged  and  critical  investigation. 

Schomerus  found  that  among  1014  operations  for  gastric  le- 
sions, 71  or  7  per  cent,  were  for  hour-glass  stomach.  Among  154 
operations  for  hour-glass  stomach  which  he  studied,  128  were  in 
females  and  26  in  males.  The  chief  cause  of  acquired  hour-glass 
contraction  is  preceding  gastric  ulcer,  but  some  cases  are  due  to 
cancer,  usually  to  that  form  which  has  developed  as  a  consequence 
of  benign  ulceration;  others  are  caused  by  pressure  of  neighbouring 
organs,  as  corset*  liver;  Rasmussen,  according  to  Schomerus, 
thought  that  hour-glass  stomach  might  be  caused  by  pressure  of 
the  left  costal  border;  some  cases  are  caused  by  perigastric  adhe- 
sions; and  a  few  are  produced  by  the  ingestion  of  corrosive  liquids, 
as  in  a  case  recorded  by  Klein,  in  which  operation  was  done  by 
Schnitzler.  Other  cases  of  hour-glass  stomach,  due  to  the  ingestion 
of  acids,  have  been  recorded  by  Carle,  Gersuny,  Hacker,  and  Korte. 
Syphilitic  ulceration  is  a  rare  cause  (Guillemot).  Langenbuch 
recorded  a  case  accompanied  by  tuberculous  ulceration  in  both 
pouches;  but  the  aetiological  relation  of  the  ulcers  was  doubtful. 

Clinical  Pathology. — The  constriction  is  usually  single,  situ- 
ated somewhat  nearer  the  pyloric  than  the  cardiac  orilice,  and  the 
greater  curvature  is  more  often  drawn  up  toward  the  lesser,  than 
the  reverse.  But  while  these  are  the  usual  characteristics,  a  great 
variety  of  deformities  has  been  encountered.  In  the  cases  studied 
by  Schomerus  the  constriction  was  near  the  pylorus  in  51,  midway 
between  the  orifices  in  34,  and  near  the  cardia  in  only  13   patients. 

When   the    pyloric   pouch    is  large  there  are   two   dangers — the 


Hour-o-lass  Stomach  and  Gastric  Diverticula. 


t' 


first  and  more  common  is  that  at  operation  the  cardiac  pouch  may 
be  entirely  overlooked,  and  a  gastro-enterostomy  done  with  the 
pyloric  portion,  without  improving  the  patient's  condition.  This 
error,  according  to  Lieblein  and  Hilgenreiner,  has  been  made  by 
Bier,  Czerny,  Kiister,  Hartmann,  and  others.  All  the  known 
cases  have  been  attended  by  a  fatal  result.  The  other  danger 
is  that  an  unusually  large  pyloric  pouch  may  be  the  seat  of  volvulus, 
as  in  cases  recorded  by  Langerhans,  Doyen,  and  others,  the  greater 
curvature  ascending  toward  the  left,  and  adding  the  factor  of  strangu- 


FiG.  23. — ^Hour-Glass  Stomach  from  Carcinomatous  "Saddle"  Ulcer  on  Lesser 
Curvature  with  Perforation.     {Half  Natural  Size.) 

lation  to  the  ijre-cxislent  obstruction.     Volvulus  of  a  large  cardiac 
pouch  docs  not  appear  to  have  been  observed. 

The  frer|uency  with  which  pyloric  stenosis  complicates  hour- 
glass .stomach  has  been  much  emphasized  l)y  Rolxson  and  Moyni- 
han.  The  stenosis  in  both  situations  may  be  due  to  ulcer,  or  one 
may  be  cau.sed  by  perigastric  adhesions.  These  adhesions  may 
act  as  a  bridle,  passing  across  the  stomach  from  one  curvature  to 
the  other,  or  the  stomach  may  itself  l)ecome  adherent  to  the  neigh- 
bouring  organs   or  to  the  anterior  al)dominal    wall.     In    one    case 


Hour-glass  Stomach. 


189 


of  trifid  stomach,  recorded  by  Robson  and  Moynihan,  both  con- 
strictions were  due  to  ulceration;  in  their  second  patient  one  con- 
striction was  caused  by  ulcer,  the  other  by  adhesions.  Dilatation 
of  the  duodenum  should  not  be  mistaken  for  hour-glass  stomach. 
Christian  has  recorded  an  interesting  case  in  which  such  an  error 
was  made. 

A  saddle   ulcer   on  the  lesser  curvature  is   a   frequent   cause   of 


'■// 


Fig.  24. — Hour-Glass   Stomach  from  Perigastric  Adhesions.     {Half  Natural 

Size.) 

hour-glass  stomach.  In  the  case  reported  by  Astley  Ashhurst,  this 
ulcer  showed  beginning  carcinomatous  change.  It  puckered  up 
the  anterior  and  posterior  gastric  walls  so  as  to  draw  the  greater 
curvature  up  toward  the  lesser,  although  it  was  near  this  that  the 
ulcer  had  its  origin  (Fig.  23).  In  one  patient  at  the  German 
Hospital  the  contraction  was  formed  by  extensive  perigastric  ad- 
hesions (Fig.  24),  while  in  three  others  the  cause  was   cicatrization 


190  Hour-glass  Stomach  and  Gastric  Diverticula. 

of  gastric  ulcers.  In  one  of  these  latter  patients  the  lesion  was 
thought  at  operation  to  be  malignant;  but  as  the  patient  remains 
in  good  health  more  than  four  years  after  the  operation  (gastro- 
gastrostomy  and  Finney's  pyloroplasty)  it  is  evident  that  the  clin- 
ical diagnosis  was  erroneous. 

The  symptoms  of  hour-glass  stomach  are  rarely  distinguishable 
from  those  due  to  pyloric  obstruction  caused  by  ulcer.  If  the 
constriction  is  close  to  the  cardia,  the  clinical  picture  simulates 
obstruction  of  this  orifice.  In  most  of  the  recorded  cases  the  con- 
dition has  been  found  at  autopsy,  or  has  been  met  with  unexpect- 
edly at  an  operation  for  the  relief  of  long-standing  gastric  symp- 
toms usually  thought  to  have  been  caused  by  ulceration  at  the 
pylorus. 

Hour-glass  constriction  is  one  of  the  latest  results  of  gastric 
ulceration.  Frequently  no  history  of  acute  ulceration  can  be  dis- 
covered; and  it  is  almost  always  certain  that  the  condition  when 
met  with  at  operation  has  existed  for  many  years. 

By  physical  examination  it  is  sometimes  possible  to  make  a 
positive  diagnosis  before  opening  the  abdomen.  Moynihan  in 
his  first  six  cases  made  a  correct  diagnosis  only  once  before  opera- 
tion; among  his  next  nine  patients,  however,  he  made  the  diagnosis 
in  seven  with  reasonable  certainty  before  operation.  The  detection 
of  hour-glass  contraction  by  physical  examination  depends  largely 
upon  the  use  of  the  stomach  tube.  On  filling  the  stomach  with 
liquid  through  the  tube,  Ei.selsberg  noticed  that  a  prominence  ap- 
peared first  in  the  left  hypochondrium,  and  that  a  few  seconds  later 
this  swelling  subsided,  and  a  second,  further  to  the  right,  made 
its  appearance.  The  passage  of  fluid  from  one  compartment  to 
the  other  may  sometimes  be  detected  as  a  gurgling  sound.  The 
stethoscope  is  useful  for  this  purpose,  but  care  should  be  taken 
not  to  mistake  the  normal  deglutition  sounds  or  the  pyloric  sound 
for  the  gurgle  due  to  the  passage  of  liquid  through  an  abnormal 
constriction.  IMoynihan,  after  outlining  the  empty  stomach,  gives 
a  Seidlitz  powder  in  two  portions;  the  upper  j)ouch  will  become 
distended  with  carbon  dioxide  some  seconds  before  the  lower. 
In  thin  persons  the  cautious  distention  of  the  stomach  with  air  by 


Hour-glass  Stomach.  191 

means  of  a  hand-bulb  may  render  the  bi-loculated  stomach  appreci- 
able to  percussion  and  palpation,  or  even  to  inspection.  We  have 
already  (p.  59)  expressed  our  preference  for  this  method  over 
distention  by  means  of  a  Seidlitz  powder.  When  after  a  measured 
quantity  of  liquid  has  been  poured  into  the  stomach  a  large  portion 
of  it  cannot  be  recovered,  it  may  be  assumed  that  the  lost  portion 
has  passed  into  the  pyloric  pouch  (Wolfler's  first  sign).  When, 
during  lavage,  the  water  has  all  returned  clear,  and  there  then 
comes  a  gush  of  cloudy  fluid  mixed  with  gastric  contents,  it  has 
been  assumed  by  Wolfler  (the  test  is  known  as  his  second  sign) 
that  the  clear  fluid  comes  from  the  cardiac  and  the  cloudy  from 
the  pyloric  pouch.  Under  similar  circumstances,  if  it  be  impos- 
sible to  recover  liquid  from  the  stomach  even  when  splashing  may 
be  detected  in  it,  it  may  be  assumed  that  the  fluid  and  air  are  con- 
tained in  the  pyloric  pouch,  where  the  stomach  tube  cannot  reach. 
This,  which  is  spoken  of  as  "paradoxical  dilatation,"  is  known 
as  Jaworski's  sign. 

If  all  these '  signs  were  present  in  any  one  case  it  might  be  safe 
to  conclude  that  hour-glass  constriction  of  the  stomach  existed; 
but  as  each  one  may  exceptionally  be  observed  in  other  conditions, 
notably  in  marked  gastric  dilatation,  the  assertion  before  operation 
in  these  cases  that  hour-glass  stomach  exists  is  in  many  instances 
a  happy  guess. 

A  more  satisfactory  outline  of  the  stomach  may  be  obtained  by 
means  of  the  X-ray,  applied  after  the  ingestion  of  bismuth  (see 
p.  62). 

Treatment. — When  surgical  treatment  is  undertaken  for  this 
condition  a  choice  of  operation  has  to  be  made  among  the  follow- 
ing: (i)  Digital  divulsion  of  the  constricted  orifice  by  means  of 
gastrotomy;  (2)  Gastroplasty  or  Gastro-anastomosis;  (3)  Gastro- 
gastrostomy;    (4)  Gastro-jejunostomy;    and  (5)  Partial  Gastrectomy. 

The  statistics  of  these  various  procedures  have  recently  been 
investigated  by  Schomerus.  Digital  divulsion  alone  seems  to  have 
been  employed  in  only  one  reported  case,  by  Moynihan,  who 
adopted  this  method  under  the  impression  that  he  was  dealing 
with  an  inoperable  malignant  growth.     The  patient  made  a  satis- 


192  Hour-glass  Stomach   and   Gastric  Diverticula. 

factory  recovery,  was  relieved  of  her  gastric  symptoms,  the  tumor 
disappeared,  and  she  was  still  in  good  health  more  than  two  years 
later.  Blake  employed  divulsion  in  a  patient  whose  stomach 
presented  a  tight  stricture  close  to  the  cardiac  orifice,  but  as  he 
also  did  a  gastro-jejunostomy,  in  the  pyloric  pouch,  some  of  the 
benefit  derived  from  the  intervention  may  have  been  due  to  the 
latter  procedure.  In  spite  of  the  successful  termination  in  these 
cases,  divulsion  is  not  now  an  accepted  form  of  treatment,  except 
in  rare  instances  where  the  constriction  is  so  near  the  cardia  as  to 
be  inaccessible  from  without  the  stomach.  As  in  the  case  of  pyloric 
obstruction,  divulsion  may  be  regarded  as  dangerous,  uncertain, 
and  in  ever}^  way  less  satisfactory  than  the  other  forms  of  treatment 
to  be  described. 

Gastroplasty,*  analogous  to  pyloroplasty,  is  said  to  have  been 
performed  first  by  Bardeleben  in  1889;  this  operation  was  attended 
by  a  fatal  result;  but  Krukenberg  in  1892  employed  it  successfully, 
as  did  Doyen  and  other  surgeons  soon  afterwards.  Gastroplasty 
is  limited  in  its  application  to  stomachs  where  the  constriction  is 
benign,  unattended  by  induration  or  active  ulceration,  and  where 
the  pylorus  is  not  itself  strictured.  The  employment  of  pyloro- 
plasty as  well  as  gastroplasty  would  only  be  complicating  one  not 
very  satisfactory  operation  by  another  still  less  promising.  Schloflcr 
in  one  case  complicated  by  pyloric  stenosis  sucessfully  combined 
gastroplasty  with  anterior  ante-colic  gastro-jejunostomy  in  the  pyloric 
pouch.  A  modification  of  gastroplasty,  analogous  to  Finney's  py- 
loroplasty, was  introduced  by  Kammerer,  and  has  l^een  successfully 
employed  by  him  and  Vjy  other  surgeons.  It  may  l^c  conveniently 
designated  Gastro-anastomosis.  Budinger  has  employed,  unsuccess- 
fully, a  flap  method  of  gastro])lasty. 

Each   method  may  no  doul)!  ])e   suitaljlc   in   certain   cases,  but 

*  Under  the  name  of  gastroplasty  Nicoladoni  suggested  the  substitution  of  the 
transverse  colon  for  the  stomach  after  a  circular  resection  of  the  latter.  Although 
commended  by  Kochcr,  it  docs  not  appear  to  have  been  employed,  and  is  mentioned 
here  only  to  avoid  confusion  of  terras.  The  same  term,  gastroplasty,  is  used  by 
Jcdlicka  to  describe  an  operation  consisting  in  resection  of  gastric  ulcers,  with 
restoration  of  the  gastric  wall  by  the  sliding  flap  method  commonly  adopted  in 
plastic  surgery. 


Hour-glass  Stomach.  193 

as  a  general  rule  gastroplasty  is  less  successful  than  one  of  the 
methods  presently  to  be  described.  Schomerus  has  collected  47 
cases  of  gastroplasty  for  hour-glass  stomach,  wth  5  deaths  (10.6 
per  cent,  mortality);  and  5  cases  in  which  pyloroplasty  was  also 
done  (20  per  cent,  mortality) ;  as  well  as  4  cases  in  which  gas- 
tro-jejunostomy  was  performed,  with  a  mortality  of  25  per  cent. 
Although  the  operative  mortality  (10.6  per  cent.)  of  simple  gastro- 
plasty is  thus  seen  to  be  mioderate  (some  of  the  deaths  cannot  be 
attributed  to  the  operation),  the  remote  results  have  been  disap- 
pointing. Paterson  found  that  "in  at  least  25  per  cent,  of  the 
patients  who  have  recovered,  either  no  relief  has  followed,  or  re- 
lapse has  occurred  subsequently." 

Gastro-gastrostoiny,  which,  under  the  name  of  gastro-anasto- 
mosis,  was  first  employed,  and  successfully,  by  Wolfler  in  1894, 
is  even  more  limited  in  its  application  than  is  gastroplasty.  Unless 
the  two  pouches  of  the  stomach  can  be  approximated  without 
tension,  the  operation  is  not  only  difficult  of  execution,  but  may 
be  attended  by  a  fatal  result  from  giving  way  of  the  sutures.  It 
is  therefore  contra-indicated  w^hen  the  cardiac  pouch  is  small,  when 
the  scar  is  wide-spreading,  or  when  many  adhesions  are  present. 
In  inoperable  cases  of  malignant  disease  it  is  possible  that  some 
temporary  relief  of  symptoms  might  be  thus  obtained,  but  usually 
in  these,  as  in  benign  affections,  better  results  will  follow  gastro- 
jejunostomy. The  main  indication,  we  think,  for  gastro-gastros- 
tomy  is  in  the  treatment  of  an  hour-glass  constriction  with  large 
pyloric  pouch  in  the  presence  of  p3doric  obstruction,  when  the  py- 
loric pouch  may  be  successfully  drained  by  gastro-jejunostomy. 
If  pyloric  stenosis  does  not  exist,  gastro-jejunostomy  in  the  cardiac 
pouch  is  to  be  preferred;  though  if  the  symptoms  are  due  to  dilata- 
tion of  the  cardiac  pouch  without  marked  stenosis  of  the  lumen 
betv/een  this  and  the  pyloric  pouch,  gastro-gastrostomy  may  prove 
effectual,  as  in  Wolfler's  patient.  Watson  in  1896  employed  a 
modification  of  gastro-gastrostomy,  which  not  only  complicated 
the  operation,  but  in  no  way  improved  its  results.  Schomerus  col- 
lected 19  operations  by  gastro-gastrostomy,  with  3  deaths  (16  per 
cent,  mortality),  as  well  as  2  successful  cases  in  which  gastro- 
13 


194         Hour-glass  Stomach   and  Gastric  Diverticula. 

enterostomy  was  also  done.  Paterson  concludes  that  "at  least 
30  per  cent,  of  the  patients  on  whom  this  operation  has  been  per- 
formed have  either  obtained  no  relief  or  have  relapsed." 

Gastro-jejunostomy  has  been  employed,  according  to  Scho- 
merus,  52  times  for  hour-glass  stomach.  Among  these  patients, 
6  died  (11.5  per  cent,  mortality).  Recurrences  were  extremely 
rare.  Paterson  found  only  2  recurrences  among  more  than  30 
patients  whom  he  traced;  and  in  one  of  these  the  return  of  symp- 
toms was  "clearly  due  to  the  coexistence  of  pyloric  stenosis." 
The  anastomosis  should  of  course  be  made  with  the  cardiac  pouch; 
and  as  the  existence  of  this  pouch,  and  consequently  the  presence 
of  hour-glass  stomach,  has  been  overlooked  at  operation  by  some 
very  competent  surgeons,  it  is  well  to  bear  in  mind  Moynihan's 
advice,  always  to  make  a  point  of  examining  the  whole  stomach 
from  oesophagus  to  duodenum,  before  undertaking  any  operation 
on  it  whatever.  If  pyloric  stenosis  coexists  with  hour-glass  con- 
striction, simple  gastro-jejunostomy  will  not  effect  a  cure,  unless 
the  pyloric  pouch  be  very  small  indeed.  Hacker  was  the  first 
(1895)  to  consider  the  treatment  of  double  gastric  stenosis,  and  the 
principles  which  he  then  laid  down  guide  the  surgeon  still.  His 
proposals  were:  (i)  To  combine  gastroplasty,  resection,  or  gastro- 
gastrostomy  with  pyloroplasty,  pylorectomy,  or  gastro-jejunostom}- 
in  the  pyloric  pouch;  or  (2)  that  gastro-gastrostomy  should  be  com- 
bined in  one  opening  with  gastro-jejunostomy,  so  that,  in  other 
words,  both  gastric  pouches  should  drain  through  the  one  gastro- 
intestinal anastomosis.  Mikulicz  is  said  to  have  adopted  this 
method  in  connection  with  a  gastroplasty.  Finally,  v.  Hacker  pro- 
posed a  double  gastro-jejunostomy,  uniting  each  gastric  pouch 
separately  with  a  loop  of  the  jejunum.  This  method  was  also 
advocated  (1896)  by  Wier  and  Foote,  by  whose  names  it  is  gener- 
ally known  in  this  country.  Clement,  of  Fribourg,  did  an  anterior 
gastro-jejunostomy  "in-Y"  with  double  lateral  anastomosis  to  the 
gastric  ])Ouches.  Mon])rol]t  proj)osed  a  double  gastro-jejunostomy 
"in-Y,"  after  Roux's  method  b)-  imi)l;intalion,  wliicli  appears  to 
us  a  more  complicated  operation  and  one  no  more  likely  to  be  suc- 
cessful than  that  em])loycd   by  Clement.     Of  these  various  opera- 


Hour-glass  Stomach.  195 

tive  combinations,  it  appears  to  us  that  these  are  to  be  preferred: 
(i)  With  small  cardiac  pouch,  gastro-gastrostomy  or  gastroplasty 
with  gastro-jejunostomy  in  the  pyloric  pouch;  (2)  with  large  cardiac 
pouch,  Finney's  pyloroplasty  with  gastro-jejunostomy  in  the  cardiac 
pouch;  (3)  with  very  small  pyloric  pouch  either  (a)  gastro-jejunos- 
tomy in  the  cardiac  pouch  alone,  (b)  gastro-jejunostomy  in  the 
cardiac  pouch  combined  with  gastro-gastrostomy  or  gastroplasty, 
or  (c)  lateral  gastro-duodenostomy,  that  is,  an  anastomosis  between 
the  cardiac  pouch  and  the  duodenum,  as  successfully  practised 
in  one  such  case  by  Schnitzler.  In  our  own  hands,  posterior 
gastro-jejunostomy  combined  with  gastro-gastrostomy  has  effected  a 
cure  in  two  patients;  a  third  was  successfully  treated  by  gastro- 
plasty and  posterior  gastro-jejunostomy;  while  the  fourth  patient, 
as  already  mentioned,  remains  well  more  than  four  years  after 
the  performance  of  gastro-gastrostomy  and  Finney's  pjdoroplasty. 
If  there  w^ere  malignant  disease,  our  preference  would  naturally 
be  for  excision,  where  practicable.  In  the  patient  with  irifid  stom- 
ach operated  on  by  Moynihan,  gastro-gastrostomy  was  employed 
to  unite  the  cardiac  and  median  pouches,  the  constriction  between 
the  latter  and  the  pyloric  pouch  was  dilated  by  the  fingers,  and  the 
pyloric  pouch  was  drained  by  gastro-jejunostomy.  In  Paterson's 
patient,  gastroplasty  was  employed  to  connect  the  pouches,  and 
gastro-jejunostomy  was  done  in  the  pyloric  pouch,  which  was  the 
largest  of  the  three.  His  patient  was  in  good  health  two  years  later. 
Gastrectomy  for  hour-glass  stomach,  when  the  obstruction  is 
benign,  appears  to  be  unnecessarily  severe.  Schomerus  collected 
8  such  operations,  with  only  one  death.  In  six  cases  (Bergmann, 
Hahn,  Korte,  Krause,  Kiimmell,  Zeller)  circular  gastrorrhaphy 
was  done  after  resection,  the  lumen  of  the  stomach  thus  being 
restored  without  resort  to  gastro-jejunostomy.  In  Hedlund's 
patient  the  cardiac  pouch  was  closed  by  sutures,  and  then  the  py- 
lorus was  united  with  the  posterior  wall  of  the  cardiac  portion  of 
the  stomach  by  Kocher's  method  of  implantation.  Biidinger, 
after  closing  each  portion  of  the  stomach  separately,  did  a  posterior 
retro-colic  gastro-jejunostomy.  The  only  fatal  result  was  in  Zel- 
ler's  patient  (1893),  and  was  due  to  the  perforation  of  another  ulcer. 


196  Hour-glass  Stomach  and  Gastric  Diverticula. 

Schomerus  coUected  10  operations  for  hour-glass  stomach  due 
to  malignant  disease.  The  results  in  9  may  be  seen  in  the  fol- 
lowing table : 


Operator. 

Operation. 

Immediate  Result. 

Ultimate  Result. 

Eiselsberg 

Gastro-j  ej  unostomy . 

Recovered. 

Kocher 

" 

Died  in  4  days. 

Mikulicz 

" 

Recovered. 

Died  in  3^  months. 

Schmitt 

" 

Recovered. 

Well  after  6^  months 

Moynihan 

. .     Excision      of     ulcer 
with   Gastroplasty 
and  Pyloroplasty. 

Died  in  4  days. 

.... 

Moynihan 

Jejunostomv. 

Recovered. 

Died  in  i  month. 

Robson 

Gastrectomy. 

Recovered. 

Well  after  2  years. 

Robson 

" 

Recovered. 

Well  after  i  year. 

Robson 

" 

Died  in  1 1  days. 



OPERATIONS  FOR  HOUR-GLASS  STOMACH 

(After  Schomerus.) 
Operation.  Cases. 


Resection : 8 

Digital  divulsion i 

Gastroplasty 47 

Gastroplasty  and  pyloroplasty 5 

Gastroplasty  and  gastro-jejunostomy 4 

Gastro-gastrostomy 19 

Gastro-gastrostomy  and  gastro-jejunostomy.  2 

Gastro-jejunostomy 52 


COVE  RE] 

D.     Died. 

Mortality 
Per  Cent. 

7 

I 

12.5 

I 

0 

00.0 

42 

5 

10.6 

4 

I 

20.0 

3 
16 

I 
3 

25.0 
16.0 

2 

0 

00.0 

46 

6 

"•5 

138 


17 


12.3 


REFERENCES. 

Amyand:  The  Philosophical  Transactions,  from  year  1719-1733; 
abridged  by  John  Eames,  F.  R.  S.,  and  John  Martyn. 
London  1734.  Vol.  VII,  p.  508;  from  p.  258  of  Vol. 
XXXVII  of  the  original  Transactions. 

Ashhurst,  A.  P.  C:  Amer.  Jour.  Med.  Sc,  1902,  ii,  629. 

Bakes:  Centralbl.  f.  Chir.,  1907,  xxxiv,  Beil.,  S.  60.  (It  was  impossible 
to  do  either  gastroplasty  or  gastro-gastrostomy;  so  he 
did  two  anterior  gastro-jejunostomies  with  a  long  loop  of 
jejunum,  connecting  the  two  loops  by  Braun's  anasto- 
mosis.) 

Blake:  Annals  of  Surgery,  1903,  xxxvii,  280.  (Divulsion  and  gastro- 
jejunostomy.) 

Biidinger:  Wien.  klin.  Woch.,  1901,  xiv,  837. 

Christian:  Bost.  Med.  and  Surg.  Jour.,  1907,  clvi,  609. 

Clement:   Cited  by  Monprofit,  Anjou  Med.,  Angers  1904,  xi,  129. 

Delamare  and  Dieulafe:  Bull,  et  Mem.  Soc.  Anat.  Paris,  1906,  viii,  467. 

Gardiner:  Jour.  Amer.  Med.  Assoc,  1907,  ii,  1598. 


Hour-glass  Stomach.  197 

Guillemot:  These  de  Paris,  1899;  cited  by  Schomerus,  loc.  infra  cit.,  S.  9. 

V.  Hacker:  Wien.  klin.  Woch.,  1895,  viii,  422. 

Hedlund:  Hygeia,  1900,  Ixii,  254. 

Jedlicka:   Operativ.  Behandl.  d.  chron.  Magengeschwiirs,  Prag  1904. 

Kammerer:  Annals  of  Surgery,  1903,  xxxvii,  281. 

Kausch:   Centralbl.  f.  Chir.,  1907,  xxxiv,  Beil,  S.  60. 

Klein:  Wien.  klin.  Rundschau,  1900,  xiv,  85. 

Kocher:   Textbook  of  Operative  Surgery,  London,  1903,  p.  225. 

Krukenberg:    Cited    by   Schmid-Monnard,    Munch,   med.    Woch.,  1893, 

A  358. 
Lieblein  and   Hilgenreiner:    Die    Geschwure   u.   d.    erworbenen    Fisteln 

d.    Magen-Darmkanals,    Stuttgart    1905.     Deutsche    Chir., 

Lieferung  46  c. 
Monprofit:  Anjou  Med.,  Angers  1904,  xi,  129. 
Morgagni:    De    Sedibus  et    Causis    Morborum,    Lib.   III.,  Epist.   xlviii, 

Sect.  37.     Venetiis  1761,  Tom.  11,  f.  239. 
Moynihan:  Brit.  Med.  Jour.,  1904,  i,  413. 
Nicoladoni:  See  Kocher,  loc.  cit.,  p.  225. 
Paterson:   Gastric  Surgery,  New  York,  1906,  p.  71. 
Rasmussen:     Centralbl.    f.    d.    med.    Wissenschaften,    1887,   xxv,    162; 

cited  by  Schomerus,  loc.  infra.. cit. 
Schloffer:  Wien.  klin.  Woch.,  1901,  xiv,  885. 
Schmitt:   Centralbl.  f.  Chir.,  1907,  xxxiv,  No.  31,  Beil.,  61. 
Schnitzler:   Cited  by  Klein,  Wien.  klin.  Rundschau,  1900,  xiv,  85. 
Schomerus:  Sympt.  d,  Sanduhrmagens.     Inaug.  Dissert.,  Gottingen,  1904. 
Watson:   Bost.  Med.  and  Surg.  Jour.,  1896,  cxxxiv,  338;   347. 
Wier  and  Foote:  N.  Y.  Med.  News,  1896,  i,  489. 
Wolfler:   Beitr.  z.  klin.  Chir.,  1895,  xiii,  221. 


198  Hour-glass  Stomach   and  Gastric  Diverticula. 

Gastric  Diverticula. — Distinct  diverticula  of  the  stomach 
are  verv  rare.  They  are  divided  by  systematic  writers  into  those 
due  to  pressure,  and  those  due  to  traction.  Every  case  of  dilated 
stomach  from  stenosis  is  really  an  example  of  a  pressure  diverticu- 
lum, the  deformity  in  cases  of  hour-glass  stomach  sometimes  as- 
suming a  form  more  characteristically  pouched.  Of  tKe  distinct 
diverticula,  the  form  due  to  traction  is  less  unusual,  and  is  pro- 
duced by  adhesions  between  the  stomach  and  neighbouring  struc- 
tures, especially  the  pancreas,  the  liver,  and  the  diaphragm  in 
the  region  of  the  cardia.  Examples  of  pressure  diverticula  have 
been  recorded  by  Schulten,  Kleine,  Grassberger,  Thorel,  and  Hirsch. 
Kolaczek,  Tilger,  Heubel,  Hansemann,  and  Silbermark,  among 
others,  have  described  gastric  diverticula  due  to  traction.  Zahn, 
from  whose  article  many  of  these  references  are  taken,  observed 
a  gastric  diverticulum  in  which  both  pressure  and  traction  were 
probably  causative  factors.  Horrocks  has  recorded  a  case  which 
he  regards  as  congenital. 

Almost  invariably  the  primary  cause  is  gastric  ulcer,  though 
a  few  examples  are  recorded  from  carcinoma.  If  the  pouch  is  so 
situated  and  of  such  conformation  as  to  favour  the  lodgement  of 
food,  it  may  when  thus  distended  simulate  a  malignant  tumor. 
Diagnosis  before  operation  or  autopsy  is  almost  impossible. 
Treatment  must  be  adapted  to  suit  the  condition  as  found.  Lieb- 
lein  and  Hilgcnreiner  think  that  in  case  the  diverticulum  is  small, 
and  not  prone  to  collect  gastric  contents,  a  gastro-enterostomy  will 
suffice  to  effect  a  cure,  by  relieving  pressure  and  allowing  the  dis- 
tended pouch  to  contract.  Of  course  gastrolysis  must  in  most  cases 
be  an  integral  part  of  the  operation.  In  other  cases  excision  of  the 
jjouch  will  be  rcfjuircd.  This  may  prove  a  difficult  and  dangerous 
operation.     Oastro-gaslrostomy  might  in  some  cases  be  jjreferabie. 

Only  two  patients  apjK'ar  to  have  been  subjected  to  operation. 
Kolaczek,  in  a  patient  in  whom  there  was  ])rcsenl  a  mass  in  the 
epigastric  region,  adherent  to  the  alxJominal  wall,  made  a  diag- 
nosis of  ulcerating  leiomyoma  of  the  stomacli.  This  diagnosis 
was  based  on  the  long  duration  of  ihc  tumor,  whicli  excluded  malig- 
nancy;   and    on   the  fat  I    that   he    considered    IcioniNoma   the    least 


Gastric  Diverticula.  199 

rare  form  of  benign  tumor.  He  excised  the  mass,  which  proved 
to  be  a  diverticulum  of  the  stomach  involving  the  pancreas.  The 
patient  recovered  and  was  reported  well  six  months  later.  The 
other  operation,  by  Mosetig-lMoorhof,  was  reported  by  Silbermark. 
The  diagnosis  in  this  case  was  osteomyelitis  or  malignant  growth 
of  the  left  costal  margin.  Extirpation  was  undertaken,  and  the 
gastric  pouch  was  unwittingly  opened,  without,  however,  invading 
the  general  peritoneal  cavity,  which  was  shut  off  by  adhesions. 
The  tract  was  found  to  be  lined  with  mucous  membrane,  and  a 
sound  passed  into  the  stomach  through  the  nose  came  out  through 
the  abdominal  wound.  A  tube  was  passed  into  the  duodenal  end 
of  the  stomach  from  the  wound,  and  the  gastric  opening  was  tam- 
ponaded.  One  week  later  the  abdomen  was  opened  in  the  median 
line,  the  stomach  was  dissected  free  from  the  anterior  abdominal  wall, 
the  edges  of  the  ulcerated  area,  in  which  the  diverticulum  had  formed, 
were  freshened,  and  the  stomach  was  closed  by  sutures,  reinforced 
by  an  omental  graft.  The  patient  recovered,  and  was  reported  in 
good  health  one  month  later. 

As  Kolaczek  says,  when  a  tumor  exists  in  a  female,  with  symp- 
toms of  gastralgia  and  a  manifestly  chronic  course,  the  tumor  being 
hard,  painful,  and  scarcely  at  all  increasing  in  size;  being  also 
adherent  to  the  abdominal  wall  in  the  left  epigastrium,  one  should 
first  of  all  think  of  the  possibility  of  a  traction  diverticulum  fol- 
lowing gastric  ulcer. 

REFERENCES. 

Hirsch:   Virchow's  Arch.  f.  path.  Anat.,  1903,  clxxiv,  577. 

Horrocks  and  Falconer:  Lancet,  1907,  i,  1296.     (Congenital  diverticula  of 

stomach  and  duodenum,  lined  by  pancreatic  tissue.) 
Kolaczek:   Mitth.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1896,  i,  163. 
Lieblein  and   Hilgenreiner:    "Die   Geschwiire  u.   d.   erworbenen   Fisteln 

d.  Magen-Darmkanals,"  Stuttgart  1905,  S.  255. 
Silbermark:  Wien.  klin.  Woch.,  1904,  xvii,  1269. 
Zahn:  Arch.  f.  klin.  Med.,  1899,  Ixiii,  359. 


CHAPTER  VIII. 

BENIGN  DISEASES  OF  THE  DUODENUM. 

DUODENAL  ULCER. 

Duodenal  ulcer  resembles  ulcer  of  the  stomach  in  so  many  respects 
that  much  of  what  has  been  said  of  the  latter  will  apply  equally  to 
the  former.  It  is  therefore  our  purpose  here  merely  to  indicate  the 
chief  differences  in  the  incidence,  symptoms,  clinical  course,  and 
treatment,  which  render  a  separate  discussion  of  these  conditions 
necessary. 

All  ulcers  on  the  duodenal  side  of  the  pyloric  vein,  which  runs  up- 
ward from  the  greater  curvature  of  the  stomach,  are  classed  by  Mayo 
as  duodenal.  Most  ulcers,  therefore,  formerly  classed  as  pyloric,  are 
thus  regarded  as  duodenal. 

In  regard  to  the  causes  of  duodenal  ulcer,  no  more  is  known 
than  of  those  of  ulcer  of  the  stomach.  Formerly  considered  a 
much  rarer  disease,  modern  surgery  has  caused  it  to  be  acknowl- 
edged that  it  is  encountered  almost  as  frequently  as  gastric  ulcer; 
indeed  W.  J.  Mayo  reports  that  among  193  cases,  60  were  gastric, 
119  duodenal,  and  14  had  independent  ulcers  of  the  stomach  and 
duodenum.  Duodenal  ulcer,  like  ulcer  of  the  stomach,  is  more 
frequent  in  Great  Britain  than  on  the  continent  of  Europe,  and 
probably  is  less  usual  in  Europe  even  than  in  this  country,  which 
nevertheless  probably  furnishes  fewer  cases  absolutely  and  rela- 
tively than  does  England.  Gandy  and  likewise  Dieulafoy  hold 
that  duodenal  ulcer,  like  gastric  ulcer,  is  in  most  instances  of  tox- 
emic origin.  Some  authors  hold  that  trauma  from  the  chyme 
as  it  is  squirted  through  the  pylorus  is  a  predisposing  cause  of  ulcer 
of  the  duodenum;  and  it  is  true  that  the  usual  site  of  duodenal 
ulcer    lends    support  to    this  theory.     The    influence  of    extensive 


Duodenal  Ulcer.  201 

burns  is  also  well  known,  but  not  one  of  the  theories  which  attempt 
to  explain  this  severe  complication  is  altogether  satisfactory. 

Duodenal  ulcer  seems  to  have  a  predilection  for  male  adults, 
especially  for  those  between  thirty  and  fifty  years  of  age,  whereas 
gastric  ulcer  is  most  characteristic  of  young  women  under  thirty 
years  of  age.  Notable  exceptions  to  this  rule,  however,  are  occa- 
sionally encountered.  Genrich  has  recorded  a  perforation  of  a  duo- 
denal ulcer  in  an  infant  21  hours  old;  and  Torday  reported  a  duo- 
denal ulcer  found  at  autopsy  in  an  infant  of  nine  months.  Hahn, 
according  to  Lieblein  and  Hilgenreiner,  found  at  autopsy  on  an 
infant  two  days  old  a  duodenal  ulcer  which  had  caused  death 
from  hemorrhage.  Cases  such  as  these,  in  infants,  are  no  doubt 
of  toxaemic  origin.  Among  Colhn's  273  patients,  16  (6.22  per 
cent.)  were  less  than  one  year  old.  The  following  tables,  com- 
piled from  various  sources,  give  the  statistics  bearing  on  these  points : 

AGE  INCIDENCE  OF  DUODENAL  ULCER. 
(Combined  figures  of  Krauss,  Chvostek,  Oppenheimer,  and  Collin.) 
Age.  No.  of  Cases.  Age.  No.  op  Cases. 

Under  lo  years : 40  5°  to    60  years 72 

ID   to   20      " 26  Goto    70      "     30 

20   to  30      "     60  70  to    80      "     21 

30   to  40      "     88  80  to    90      "     3 

40   to   50      "     69  90  to  100      "     3 

ANALYSIS  AS  TO  SEX. 
Author.  Cases. 

Alloncle 44 

Chvostek 61 

Collin 257 

Grunfeld 4 

Krannhals 6 

Krauss 64 

Lebert 39 

Oppenheimer 79 

Trier 54 

Mayo 272 

Robson 66 

Duodenal  ulcer  is  more  often  single  than  gastric  ulcer,  although 
it  is  more  usual  for  it  to  invade  the  pylorus,  and  thus  become  partly 
gastric,  than  for  it  to  exist  isolatedly  in  the  duodenum.  In  the 
immense  majority  of  cases  the  ulcer  occupies  the  region  of  the 
duodenum    above    the    entry    of    the    bile-ducts.      The  descending 


Male. 

Female. 

Ratio. 

42 

2 

21:1 

44 

17 

3:1 

205 

52 

4:1 

3 

I 

3:1 

3 

58 

3 
6 

1:1 

10:1 

31 
56 

8 
23 

4:1 
2:1 

45 
209 

57 

9 

63 

9 

5:1 

3^:1 

6:1 

202  Benign  Diseases  of  the  Duodenum. 

portion  of  the  duodenum  is  very  seldom  affected,  and  the  trans- 
verse is  still  more  rarely  the  seat  of  ulceration.  By  combining 
the  statistics  of  Perry  and  Shaw,  of  Oppenheimer  and  of  Collin, 
we  find  that  duodenal  ulcer  occurred  in  the  first  portion  in  434 
cases  (92  per  cent.);  in  the  descending  portion  in  28  cases  (6  per 
cent.);  and  in  the  third  portion  in  12  cases  (2  per  cent.).  Statis- 
tics as  to  the  location  of  the  ulcer  on  the  circumference  of  the  duo- 
denum vary;  our  own  impression,  from  experience  at  operation 
and  in  the  dissecting  room,  is  that  it  is  more  frequently  seen  on 
the  upper  wall  of  the  first  portion  of  the  duodenum  than  elsewhere. 
Collin  found  it  71  times  on  the  anterior  wall,  45  times  on  the  poste- 
rior, ID  times  on  the  upper,  and  only  once  on  the  lower  wall  of  the 
duodenum. 

Symptoms. —  While  in  general  characteristics  the  symptoms 
of  ulcer  of  the  duodenum  bear  a  close  resemblance  to  those  of 
gastric  ulcer,  there  are  certain  factors  sufficiently  distinctive,  if 
they  be  present,  to  render  possible  a  positive  diagnosis  of  the  site  of 
the  lesion. 

Duodenal  ulcer  is  even  more  apt  to  be  latent  than  is  ulcer  of 
the  stomach.  Perforation  is  quite  usually  the  first  symptom  calling 
for  medical  advice.  Among  151  cases  analyzed  by  Perry  and  Shaw 
the  first  sym.ptom  in  no  less  than  91  was  the  hemorrhage  or  per- 
foration from  which  the  patient  died.  F.  Brunner  found  a  history 
of  i)revious  symptoms  of  duodenal  ulcer  could  be  obtained  in  only 
56  per  cent,  of  the  ])atients  with  perforation  whose  cases  he  analyzed. 
Weir,  however,  found  the  previous  history  positive  on  this  point  in 
25  (73  per  cent.)  of  34  cases  of  duodenal  perforation. 

Pdin  in  duodenal  ulcer  t\'j)i(ally  docs  not  occur  until  two  or  three 
hours  after  the  ingestion  of  food.  Indeed  many  patients  will  entirely 
deny  the  existence  of  pain,  and  only  on  close  questioning  will  admit 
that  they  feel  more  comfortable  when  the  stomach  has  some  food  in 
it,  then  the)-  do  soon  before  taking  llicir  meals.  They  frequently 
acknowledge  that  they  are  a\erse  to  letting  IJieir  stomachs  remain 
emj^ty  more  than  two  or  three  hours  at  a  time.  'I'hey  will  not  sleep 
soundly  the  night  tlirough  unless  they  have  eaten  a  lillle  late  suf)])er 
just  before  retiring;    or  they  will  be  in  ihc  habit  of  taking  a  cracker 


Duodenal  Ulcer.  203 

and  a  glass  of  milk  during  the  night  when  they  wake  up  in  the  small 
hours.  All  these  are  manifestations  of  what  Mayo  Robson  has 
graphically  called  the  "hunger  pain"  of  duodenal  ulcer.  But  it  is 
to  be  noted  that  patients  are  rarely  aware  that  it  is  the  discomfort 
which  impels  them  to  keep  their  stomach  constantly  occupied.  They 
rather  think  that  the  eating  at  shorter  intervals  than  other  people 
is  an  idiosyncrasy  not  based  on  any  pathological  cause.  It  is  quite 
generally  acknowledged  that  the  reason  the  presence  of  food  in  the 
stomach  keeps  in  abeyance  the  pain,  is  because  thus  the  acid  gastric 
secretion  is  neutralized  before  passing  the  pylorus,  and  thus  irritation 
of  the  ulcer  is  prevented.  Pain  is  less  often  referred  than  in  ulcer  of 
the  stomach.  But  it  must  be  confessed  that  gastric  ulcer  so  often 
exists  along  with  an  ulcer  in  the  duodenum,  that  these  distinctive 
signs  are  often  lacking. 

Vomiting  is  unusual  in  duodenal  ulcer,  unless  stenosis  of  the 
pylorus  is  present.  Hamatemesis  is  equally  rare.  Melana,  on  the 
other  hand,  is  as  usual  in  ulcer  of  the  duodenum  as  is  haematemesis 
in  gastric  ulcer.  The  quantity  of  blood  in  the  bowel  movements, 
however,  is  frequently  very  small,  and  often  escapes  the  attention 
of  the  patient  altogether.  The  tests  for  occult  blood  are  then  of 
great  aid  in  reaching  a  diagnosis. 

Tenderness  in  duodenal  ulcer  is  almost  invariably  'close  to  the 
right  costal  border,  and  characteristically  is  not  confined  to  one 
spot,  but  extends  through  the  descending  portion  of  the  duodenum. 

Jaundice  is  a  rare  sign,  and  is  generally  thought  to  indicate 
that  the  papilla  of  Vater  is  invaded  by  the  ulcer,  though  it  may  be 
due  merely  to  concurrent  catarrhal  duodenitis. 

Perforation  is  much  more  frequent  than  in  gastric  ulcer.  About 
fifteen  per  cent,  of  patients  with  ulcer  of  the  stomach  die  from 
perforation,  whereas  of  those  with  duodenal  ulcer  probably  one- 
fourth  will  develope  this  complication.  Laspeyres  gives  the  follow- 
ing statistics  in  regard  to  the  frequency  of  perforation  in  ulcer  of 
the  duodenum:  Chvostek  found  it  to  occur  in  42  per  cent,  of  pa- 
tients, Collin  in  69  per  cent.,  and  Oppenheimer  in  48  per  cent,  of 
patients.  Among  272  operations  for  duodenal  ulcer  Mayo  records 
66  for  perforation  (16  acute,  13  subacute,  and  37  chronic  perfora- 


204  Benign  Diseases  of  the  Duodenum. 

tions).  According  to  F.  Brunner,  perforation  is  more  frequent 
in  America  than  elsewhere,  being  next  most  frequent  in  France 
and  Switzerland.  This  frequency  he  attributes  to  the  excessive 
use  of  alcoholic  stimulants.  From  the  statistics  he  collected  he 
found  perforation  of  duodenal  ulcer  occurred  ten  times  in  the  male 
to  once  in  the  female ;  whereas  perforation  of  gastric  ulcer  occurred 
only  once  in  the  male  to  four  times  in  the  female. 

The  perforation  is  much  most  frequent  in  the  first  portion  of 
the  duodenum,  and  usually  is  on  its  anterior  wall. 

SITE  OF  PERFORATION  OF  THE  DUODENUM. 
Author.  First.  Descending.  Transverse.  Total  Cases. 

Brunner 62  7  3  72 

Oppenheimer 34  3  o  37 

Perry  and  Shaw 48  2  i  51 

Total 144  12  4  160 

Percent 90  7.5  2.5  100 

SITE  OF  PERFORATION  IN  FIRST  PART  OF  DUODENUM. 
(After  Laspeyres.) 
Author.  Anterior  Wall.   Superior  Wall.    Posterior.        Inferior.         Total. 

Oppenheimer 11  i  3  o  15 

Perry  and  Shaw 19  o  6  o  25 

ColHn 71  10  45  I  127 

Total loi  II  54  I  167 

Percent 60.5  6.5  32  i  100 

Among  the  62  perforated  ulcers  in  the  first  part  of  the  duodenum 
recorded  by  Brunner,  9  were  on  the  posterior  wall,  38  were  on 
the  anterior  and  upper  wall,  while  in  15  cases  the  site  of  the  per- 
foration was  not  mentioned. 

The  rarity  of  perforation  on  the  lower  wall,  as  well  as  on  other 
retro-peritoneal  portions  of  the  duodenum,  is  no  doubt  due  to  the 
protection  afforded  by  the  pancreas  and  other  retro-peritoneal 
structures.  Were  the  duodenum  provided  with  a  mesentery,  per- 
forations of  its  lower  wall  might  occur  more  frequently,  but  even 
then  perforations  would  still  be  more  apt  to  occur  at  the  point  of 
poorest  blood  supply.  Perforations  into  neighbouring  organs  have 
seldom  been    observed.      J'crforation  of    the  duodenum    into    the 


Duodenal  Ulcer.  205 

stomach  appears  to  be  unknown;  that  of  the  stomach  into  the 
duodenum,  though  extremely  rare,  has  nevertheless  been  recorded 
in  a  few  instances.  Subphrenic  abscess  was  caused  by  duodenal 
perforation  in  6  out  of  58  cases  of  the  former  condition  collected 
by  Nowak. 

In  regard  to  symptomatology  of  perforation  of  duodenal  ulcer, 
little  need  be  added  to  what  has  already  been  said  (at  p.  86)  in 
connection  with  gastric  perforations.  The  great  frequency  with 
which  duodenal  perforation  simulates  appendicitis  should  be  borne 
in  mind.  Moynihan  in  1901  collected  49  operations  for  perfora- 
tion of  the  duodenum,  in  18  of  which  the  diagnosis  had  been  appen- 
dicitis. If  at  an  operation  undertaken  for  appendicitis,  especially 
in  a  male  adult,  no  lesion  of  the  appendix  be  found  suilicient  to 
account  for  the  state  of  the  peritoneal  cavity,  the  surgeon  will  do 
well  immediately  to  examine  the  region  of  the  pylorus.  In  very 
many  cases  his  search  for  perforation  will  be  rewarded.  The 
presence  of  gas  in  the  peritoneal  cavity  is  a  sign  usually  indicative 
of  perforation  rather  high  in  the  intestinal  tube. 

Prognosis. — There  can  be  no  question  that  ulcer  of  the  duo- 
denum is  a  graver  disease  than  is  gastric  ulcer ;  its  greater  liability 
to  fatal  hemorrhage  and  to  perforation  make  a  sudden  death  prob- 
able in  about  half  the  cases,  unless  some  treatment  can  be  applied 
which  will  not  only  relieve  the  symptoms,  but  entirely  cure  the 
disease.  Medical  treatment  is  of  course  available,  and  if  adopted 
as  soon  as  the  disease  is  suspected  may  in  some  cases  allow  the 
ulcer  to  heal.  If  this  happy  event  occurs,  it  is  not  probable  that 
further  trouble  will  be  caused  by  obstruction  from  the  cicatrix. 
Yet  in  rare  instances  hourglass  duodenum  has  developed;  and  in 
not  a  few  patients  it  seems  likely  that  persistence  or  recurrence  of 
indigestion  after  so  called  medical  cure,  may  be  due  to  cicatricial 
contraction. 

Surgical  treatment  offers  for  duodenal  ulcer  no  less  sure  a  cure 
than  for  ulcer  of  the  stomach,  and  the  mortality  of  operation  for 
non-perforated  cases  is  no  higher.  Robson,  in  an  excellent  review 
of  the  subject,  reports  his  own  series  of  66  operations  for  unper- 
forated  duodenal  ulcer,  with  no  deaths  attributable  to  the  opera- 


2o6  Benign  Diseases  of  the  Duodenum. 

tion.  Mayo  reports  an  operative  mortality  of  2.8  per  cent,  among  119 
cases  treated  in  igo6  and  1907.  Robson  is  of  the  opinion  that  the 
symptoms  of  duodenal  ulcer  have  only  lately  become  well  recognized, 
and  thinks  that  therefore  the  proportion  of  cases  which  perforate,  as 
usually  given,  is  too  high,  because  in  these  statistics  only  the  severest 
cases  of  duodenal  ulcer  are  included.  Thus  he  says  that  in  his  own  ex- 
perience perforation  has  occurred  in  only  10  per  cent,  of  cases; 
and  he  adds,  what  is  a  consideration  of  the  utmost  consequence, 
that  he  is  convinced  he  has  by  timely  resort  to  gastro-jejunostomy 
effectually  prevented  perforation  from  occurring. 

The  prognosis  when  perforation  has  actually  occurred,  is  much 
less  favourable.  Mayo  reports  3  deaths  among  16  acute  perforations, 
no  deaths  among  13  subacute,  and  i  death  among  37  chronic  perfora- 
tions of  the  duodenum.  Although  Robson  speaks  hopefully  of  the 
mortality  from  this  cause  being  reduced  to  5  or  10  per  cent,  for  those 
patients  operated  on  within  twelve  hours  of  perforation,  it  scarcely 
seems  likely  that  such  excellent  results  can  be  obtained  in  the  near 
future.  The  actual  figures  collected  by  Robson,  comprising  155 
operations  from  various  sources,  gave  a  total  mortality  of  66  per 
cent.,  as  may  be  seen  in  the  following  table: 

OPERATIONS  FOR  DUODENAL  PERFORATION. 

Mortality 
Time.  Cases.  Recovered.  Died.  per  cent. 

Under  24  hours 61  38  23  37.7 

Over  24  hours 63  11  52  82.5 

Not  stated 31  3  28  90.3 

Total 155  52  103  66.66 

Treatment. —  Surgical  treatment  for  duodenal  ulcer  was  at 
first  confined  solely  to  tlic  attcmi^tcd  repair  of  perforations;  and 
it  is  not  until  within  the  last  five  or  six  years  that  the  cure  of  the 
ulcer  has  been  undertaken,  by  resort  to  gastro-enterostomy  or 
other  similar  operation.  According  to  Weir,  it  was  Sidney  Jones 
in  1888,  who  Jirst  operated  on  a  jjatienl  with  a  duodenal  i)erfora- 
tion.  No  diagnosis  other  tlian  peritonitis  was  made,  and  the 
jjcrforation  was  discovered  onl\'  at  tlie  autopsy.  Four  similar 
operations,  with  fatal  results,  followed  Ihis  first  resort  to  surgery, 
and  it  remained  for  Oould  to  find  and  to  sulurc  llic  uIcct,  although 


Duodenal  Ulcer.  207 

his  patient  survived  only  six  hours.  Five  other  fatal  operations 
followed  Gould's;  but  finally  a  patient  operated  on  by  Dean,  in 
1894,  recovered  from  the  operation,  but  died  two  months  later 
from  intestinal  obstruction.  The  patient  of  Landerer  and  Glucks- 
mann  (1896)  survived  six  months,  and  then  died  of  another  perfo- 
ration of  the  duodenum;  but  Dunn's  patient,  operated  on  in  this 
same  year,  is  credited  with  permanent  recovery. 

As  a  prophylactic  against  perforation,  and  as  a  cure  for  the 
ulceration,  gastro-enterostomy  is  the  most  successful  form  of  surgical 
treatment.  Among  the  earliest  surgeons  to  resort  to  this  operation 
in  non-perforated  duodenal  ulcer,  according  to  Pagenstecher,  was 
Codivilla;  his  patient  recovered  and  was  in  good  health  five  years 
later;  Berg  and  Roux  are  also  mentioned  by  Weir  as  among  the 
first  to  operate  for  non-perforated  ulcer  of  the  duodenum.  Ex- 
cision of  the  ulcer,  with  gastro-duodenostomy,  can  only  rarely  be 
advisable.  We  have  never  seen  a  case  in  which  posterior  gastro- 
jejunostomy did  not  seem  preferable.  Even  if  the  pylorus  is 
patent,  it  is  seldom  necessary  to  occlude  it  by  ligature  or  otherwise. 
If  modern  gastro-jejunostomy  (/.  e.,  the  posterior  operation  with- 
out a  loop)  be  adopted,  the  vicious  circle  and  regurgitant  vomiting 
will  be  found  to  have  become  things  of  the  past. 

When  perforation  has  occurred,  operation  at  the  earliest  possible 
moment  is  demanded.  Shock  is  no  contraindication  to  operation. 
The  shock  is  due  largely  to  the  perforation  and  to  the  gas  in  the  peri- 
toneal cavity;  and  the  sooner  the  surgeon  opens  the  peritoneum, 
allows  the  gas  to  escape,  and  then  closes  the  hole  in  the  duodenum 
by  which  it  first  made  its  exit,  the  better  it  will  be  for  his  patient. 
A  large  sand  pillow  under  the  lumbar  spine  will  aid  materially  in 
bringing  the  duodenum  up  into  the  operative  field ;  and  in  case 
this  proves  particularly  dilScult,  it  will  be  well  to  "mobilize"  the 
duodenum.  The  perforation  is  to  be  sutured;  Lembert  sutures, 
preferably  of  the  mattress  type,  are  the  best;  and  if  the  sutures 
do  not  hold  well,  a  tag  of  omentum  should  be  stitched  over  the 
sutured  area.  Unless  there  is  a  history  of  indigestion  of  long  stand- 
ing, and  unless  the  peritoneum  is  only  slightly  soiled  and  the  patient 
in  very  good  condition,  it  is  not  usually  recommended  to  perform 


2o8  Benign  Diseases  of  the  Duodenum. 

gastro-jejunostomy  at  the  same  sitting.  In  cases  where  operation 
is  done  in  a  few  hours  after  perforation,  we  think  gastro-jejunostomy 
may  properly  be  done  also;  but  if  peritonitis  is  extensive,  it  had 
best  be  postponed.  After  a  few  weeks  or  a  month  this  operation 
may  be  done  with  the  utmost  safety,  and  with  every  prospect  of 
affording  the  patient  a  permanent  cure.  Especially  true  is  this 
in  cases  of  subacute  perforations  of  the  stomach  and  duodenum. 
The  first  and  most  important  thing  in  such  cases  is  to  arrest  and 
to  cure  the  peritonitis;  and  only  when  the  peritoneum  is  healthy 
should  an  operation  such  as  gastro-jejunostomy  be  employed. 

Robson  has  called  attention  to  the  importance  of  treating  pan- 
creatitis when  present  as  a  complication  of  duodenal  ulcer.  Ref- 
erence has  already  been  made  to  the  occasional  presence  of  jaundice 
in  patients  with  ulcer  of  the  duodenum;  and  when  this  is  a  recur- 
rent or  a  persistent  symptom,  and  especially  if  fever  and  other 
evidences  of  infection  develope,  the  presence  of  cholangitis  and 
pancreatitis  should  be  suspected.  Under  such  circumstances  we 
have  resorted  to  cholecystotomy  with  drainage,  with  the  most 
gratifying  results ;  and  where  very  prolonged  or  permanent  drain- 
age is  indicated,  it  will  be  proper  to  do  a  cholecysto-enterostomy — 
an  operation  which  has  been  practised  with  success  under  such 
conditions  by  Mayo  Robson. 

REFERENCES. 

Bninner,  F.:  Deutsch.  Zeit.  f.  Chir.,  1903,  Ixix,  106;   178. 

Gandy:  These  cle  Paris,  1899. 

Genrich:  Cited  by  Gandy,  loc.  cit. 

Gould:  Middlesex  Hospital  Reports,  1893,  p.  168. 

Laspeyres:   Centralbl.  f.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1902,  v,  34. 

Lieblein   and   Hilgcnreiner:    Die    Geschwiire  u.  d.  erworbenen  Fisleln  d. 

Magen-Darmkanals,  Stuttgart,  1905. 
Mayo:   Annals  of  Surgery,  1907,  i,  810. 
Moynihan:   Lancet,  1901,  ii,  1656. 
Nowak:   Cited  by  Laspeyres,  loc.  cit.,  S.  35. 
Pagenstecher:  Deutsch.  Zeit.  f.  Chir.,  1899,  Hi,  541. 
Perry  and  Shaw:   Guy's  Hospital  Reports,  1893,  1,  204. 
Robson:  Brit.  Med.  Jour.,  1907,  i,  248. 
Torday:  Jahrb.  f.  Kinderheilk.,  1906,  Ixiii,  563. 
Weir:  Trans.  Amer.  Surg.  Assoc,  1900,  xviii,  11. 


Imperforation — Strictures.  209 


MISCELLANEOUS  AFFECTIONS  OF  THE  DUODENUM. 

Congenital  Imperforation  of  the  Duodenum,  examples  of 
which  rare  condition  have  been  recorded  by  Cleemann,  Trump, 
Stewart,  and  others,  could  be  differentiated  during  life  from  imper- 
foration of  the  pylorus  only  if  the  occlusion  were  below  the  papilla 
of  Vater,  thus  allowing  bile  to  be  regurgitated  into  the  stomach. 
Should  a  diagnosis  be  made,  gastro-jejunostomy  should  be  per- 
formed ;  but  as  malformations  of  the  bile  ducts  and  liver  sometimes 
co-exist,  the  prognosis  is  exceptionally  gloomy.  In  the  cases  just  re- 
ferred to,  the  occlusion  was  below  the  papilla  of  Vater;  in  cases 
reported  by  CoUum,  Emerson,  Hobson,  and  others,  it  was  situated 
above  the  entrance  of  the  bile  ducts.  Shaw  and  Baldauf  have  re- 
corded a  case  of  congenital  stricture  of  the  duodenum  in  a  girl  aged 
13  days;  the  lumen  was  found  at  autopsy  to  be  permeable  only 
to  fluids  under  pressure.  They  quote  Kuliga  as  having  collected 
185  cases  of  congenital  occlusion  of  the  intestines;  of  these,  46 
(25  per  cent.)  were  of  the  duodenum,  94  of  the  jejunum,  and  45 
of  the  colon  and  rectum.  Perry  and  Shaw  refer  to  7  cases  of  con- 
genital stenosis  of  the  duodenum. 

REFERENCES. 

Cleemann:  Phil,  Med.  Times,  1874-5,  v,  59. 

CoUum:  Trans.  Pathol.  See.  London,  1895,  xlvi,  60. 

Emerson:  N.  Y.  Med.  Jour.,  1890,  lii,  153. 

Hobson:  Brit.  Med.  Jour.,  1893,  i,  637. 

Perry  and  Shaw:   Guy's  Hospital  Reports,  1893,  1,  171. 

Shaw  and  Baldauf:  Archives  of  Pediatrics,  1907,  xxiv,  813. 

Stewart:  Medicine,  Detroit,  1898,  iv,  994. 

Trump:  Mlinch.  med.  Woch.,  1896,  xhii,  747. 

Strictures  of  the  Duodenum  sometimes  result  from  cicatriza- 
tion of  ulcers.  Affections  of  the  biliary  tract  (calculi)  or  pancreas 
(pancreatitis  or  carcinoma)  are  more  frequent  causes.  Albu 
collected  43  cases  of  stenosis  of  the  duodenum,  at  least  15  of  which 
were  due  to  affections  of  the  pancreas.  The  operation  which  has 
14 


210  Benign  Diseases  of  the  Duodenum. 

been  adopted  in  cases  of  duodenal  stricture  by  Bslzj,  Mackenzie 
and  others,  is  named  duodenoplasiy,  and  consists  in  longitudinal 
incision  and  transverse  suture  of  the  constricted  portion  of  bowel. 
If  the  adhesions  are  few  or  easily  separated,  and  the  duodenal  wall 
not  too  thick  or  friable,  this  is  a  better  procedure  than  gastro-enter- 
ostomy  in  cases  of  stenosis  due  to  changes  in  the  intestinal  wall, 
and  is  the  only  rational  operation  in  simple  strictures  close  below 
the  papilla  of  Vater.  If  the  stricture  were  entirely  retro-peritoneal 
in  position,  as  in  the  transverse  duodenum,  a  duodeno-jejunostomy 
on  the  proximal  side  of  the  obstruction  might  be  possible. 

REFERENCES. 

Albu:   Centralbl.  f.  d.  Grenzgeb.  d.  inn.  Med.  u.  Chir.,  1899,  ii,  145. 
Bazy:   Bull,  et  Mem.  Soc.  Chir.  Paris,  1905,  xxxi,  193. 
Mackenzie:  Jour.  Amer.  Med.  Assoc,  1906,  ii,  341. 

Chronic  Dilatation  of  the  Duodenum  is  occasionally  seen. 
It  is  usually  due  to  an  obstruction  either  at  the  duodeno-jejunal 
flexure  or  to  pressure  from  the  superior  mesenteric  artery.  The 
duodenal  sphincter  described  by  Ochsner  may  be  an  unrecognized 
cause.  Finney  has  called  special  attention  to  chronic  dilatation 
of  the  duodenum,  and  in  discussing  his  paper  Prof.  Barker  sug- 
gested duodeno-jejunostomy  as  a  remedy.  This  operation  has 
been  emjjloyed  successfully  by  Stavely.  We  have  observed  this 
condition  in  a  number  of  cases  of  gastric  and  biliary  affections, 
and  have  little  doubt  that  many  patients  with  symptoms  of  pyloric 
obstruction  who  are  found  to  have  a  patent  pylorus  are  suffering 
from  dilatation  of  the  duodenum.  Christian  has  recorded  a  case 
where  chronic  dilatation  of  the  duodenum  was  mistaken  for  hour- 
glass stomach. 

REFERENCES. 

Christian:   Bost.  Med.  and  Surg.  Jour.,  1907,  clvi,  609. 
Finney:  Johns  Hopkins  Hosp.  JiuU.,  1906,  xvii,  37. 
Ochsner:  Annals  of  Surgery,  1906,  i,  80. 
Stavely:  Johns  Hopkins  Hosp.  Jkill.,  1908. 

Hour-glass  Duodenum  usually  is  a  late  result  of  stricture, 
following  ulceration.     The  stricture  is  usually  above  the  bile  pa- 


Diverticula  of  the  Duodenum.  211 

pilla,  frequently  close  to  the  pylorus.  Mackenzie  has  lately  pub- 
lished details  of  several  cases  of  this  malformation,  and  suggests 
a  number  of  operations  for  its  relief.  He  has  himself  employed 
gastro-jejunostomy  in  two  patients  under  his  care :  cure  resulted 
in  the  first,  which  appears  to  have  been  a  stricture  rather  than 
an  example  of  true  hour-glass  deformity;  but  the  second  patient, 
presenting  a  well-marked  deformity,  though  much  improved  by 
the  operation,  still  had  considerable  gastric  discomfort.  Prefer- 
able operations  are  duodenoplasty  (Ladeveze,  Bazy,  Mackenzie) ; 
duodeno-duodenostomy  (Mayo);  or  gastro-duodenostomy  to  the 
distal  pouch  of  the  duodenum.  All  these  procedures  are  much  more 
readily  executed  after  mobilization  of  the  duodenum.  Riegel 
and  Hollscher  also  are  said  to  have  reported  cases  of  hour-glass 
duodenum. 

REFERENCE. 
Mackenzie:  Jour.  Amer.  Med.  Assoc,  1906,  ii,  34-1. 

Diverticula  of  the  D-aodenum  have  been  noted  by  several 
observers.  It  was  Morgagni  who  first  described  the  condition. 
Letulle  noted  in  two  cases  little  pouches  in  the  neighbourhood  of 
the  bile  papilla,  and  thought  they  were  to  be  explained  as  a  con- 
genital anomaly  of  developement  due  to  the  budding  out  from  the 
duodenum  of  processes,  as  in  the  formation  of  the  liver  and  pan- 
creas. The  patient  recorded  by  Pilcher  had  a  large  retro-peri- 
toneal cyst,  opened  at  operation  above  the  ileum  and  to  the  left 
of  the  ascending  colon;  the  cyst  at  autopsy  was  found  to  be  in 
communication  with  the  lumen  of  both  duodenum  and  jejunum, 
being  intercalated  in  the  intestinal  tract  between  these  structures, 
and  having  formed  as  the  result  of  extensiv^e  destruction  of  the 
transverse  portion  of  the  duodenum  from  ulceration. 

Perry  and  Shaw  classify  diverticula  of  the  duodenum  as  disten- 
sion and  traction  pouches.  Usually  found  close  to  the  papilla, 
as  in  Letulle's  patients,  they  are  next  most  frequent  at  the  pylorus. 
They  usually  produce  no  symptoms,  and  are  found  at  autopsies 
in  the  aged.  The  developement  of  pressure  pouches  is  aided  by 
the  presence  of  the  pylorus  above  and  Ochsner's  sphincter  below. 


212  Benign  Diseases  of  the  Duodenum. 

Traction  diverticula  are  less  usual,  and  are  generally  due  to  peri- 
gastric adhesions  the  result  of  ulcer  or  cholecystitis.  Perry  and 
Shaw  mention  14  cases  of  pressure  diverticula,  and  found  at  Guy's 
Hospital  records  of  three  patients  with  traction  diverticula.  Ex- 
cision is  the  best  treatment. 

REFERENCES. 

Dorrance:  Univ.  of  Penna.  Med.  Bull.,  1908,  xxi,  48. 

Horrocks  and  Falconer:  Lancet,  1907,  i,  1296. 

Letulle:  Presse  Med.,  1899,  i,  13. 

Morgagni:  De  Sed.  et  Causis  Morb.,  Lib.  Ill,  Obs.  xxxiv,  17.  Venetiis, 

1761,  Tom.  ii,  f.  50. 
Perry  and  Shaw:  Guy's  Hosp.  Reports,  1893,  1,  171. 
Pilch er:  Annals  of  Surgery,  1894,  xx,  63. 


CHAPTER   IX. 

BENIGN    TUMORS  OF   THE    STOMACH  AND    DUODENUM. 

Benign  tumors  of  the  stomach  and  duodenum  are  rare.  As 
has  been  seen  in  the  preceding  pages,  a  palpable  mass,  when  not 
malignant,  is  almost  invariably  hyperplastic  or  inflammatory  in 
origin.  The  non-malignant  neoplasms  most  frequently  encoun- 
tered in  the  stomach  are  myoma,  adenoma  (including  polyp), 
lipoma,  and  cysts. 

Before  proceeding  to  a  detailed  account  of  each  variety,  it  will 
be  well  to  state  in  a  few  words  the  general  characteristics  which 
most  of  these  growths  possess  in  common.  Although  heretofore 
found  most  frequently  at  autopsy,  in  patients  who  as  a  rule  are  not 
known  to  have  suffered  from  gastric  symptoms  during  life,  it  is 
altogether  probable  that  with  the  increasing  number  of  operations 
on  the  upper  abdomen,  more  of  these  tumors  will  in  the  future  be 
found  at  operation,  even  if  they  may  not  have  been  correctly  diag- 
nosticated before  the  abdomen  was  opened. 

The  patient  is  usually  an  adult,  probably  more  often  female 
than  male,  who  has  suffered  from  gastric  indigestion  for  a  number  of 
years.  Pain  of  a  dragging  and  tearing  character  is  sometimes  a 
prominent  symptom.  Vomiting,  if  it  occurs  at  all,  usually  arises 
a  half  hour  or  an  hour  after  eating,  but  is  present  with  no  regularity 
as  in  gastric  ulcer.  The  vomiting  may  occur  only  once  or  twice 
during  the  whole  course  of  the  illness,  or  it  may,  especially  in  the 
case  of  polypoid  growths,  recur  Avhenever  gastric  peristalsis  is  ex- 
cited. In  very  pronounced  polypoid  conditions  of  the  mucosa, 
the  nausea  may  be  constant.  Haematemesis  is  rare,  being  seen 
most  often  in  adenomatous  tumors,  or  in  myomatous  tumors  which 
have  penetrated  the  cavity  of  the  stomach  and  have  become  ulcer- 
ated. The  blood  is  then  usually  clotted  before  being  vomited; 
the  vomiting  of  bright  red  blood  is  quite  unusual.  The  tumors  in  the 

213 


214        Benign  Tumors  of  the  Stomach  and  Duodenum. 

course  of  time  are  prone  to  excite  perigastritis,  and  the  adhesions 
both  interfere  with  gastric  motihty,  and  cause  increased  pain. 
Frequently  the  tumor,  though  of  fair  size,  is  not  palpable  because 
held  by  adhesions  beneath  the  costal  margin,  or  because  perigas- 
tritis renders  the  overlying  muscles  so  rigid  that  satisfactory  pal- 
pation is  impossible.  Large  subserous  tumors  of  the  stomach  with 
a  long  pedicle  may,  on  the  contrary^  be  very  movable,  and  oc- 
casionally are  found  even  in  the  hypogastric  region.  The  physical 
signs  of  hour-glass  stomach  may  be  simulated  by  submucous 
growths  in  the  median  portion  of  the  stomach. 

The  long  duration  of  a  palpable  mass  is  the  chief  means  by 
^\■hich  malignant  disease  may  be  excluded.  A  diagnosis  of  benign 
tumor  is  sometimes  made  in  cases  of  inflammatory  hyperplasia; 
and  Kolaczek,  as  already  mentioned  (p.  199),  diagnosed  leiomyoma 
in  a  patient  with  a  gastric  diverticulum  adherent  to  the  anterior 
abdominal  wall. 

Myoma  and  Fibromyoma.  Myoma  of  the  stomach  was 
first  observed  by  Morgagni.  Steiner  in  1898  collected  58  cases 
of  myoma  of  the  gastro-intestinal  canal,  21  of  which  were  situated 
in  the  stomach,  and  only  3  in  the  duodenum.  To  these  cases  of 
gastric  myoma  may  be  added  28  additional  cases  recorded  by: 
Borrmann,  Bouveret,  Caminiti,  Cappello  and  Cappello,  Cernezzi, 
Cohn  (2  cases).  Cutler,  Ehrenbcrg,  Goullioud  (2  cases),  Jean,  Kidd, 
IMagnus-Alsleben  (5  cases  of  adeno-myoma),  Miodowski,  Monro, 
Moser  (3  cases),  Noll,  Perls  and  Neelsen,  Poiricr,  Samtcr,  and 
Yates. 

These,  with  the  21  cases  collected  by  Steiner,  make  a  total  of 
49  cases  of  gastric  myoma  recorded  to  date,  so  that  it  can  no  longer 
be  regarded  as  an  excessively  rare  condition.  It  is  probable, 
moreover,  that  very  small  myomata  are  sometimes  overlooked  at 
autopsy.  Among  3500  autopsies  at  Genf,  Tilger  found  6  nut-sized 
myomata  and  fibromyomala  of  the  stomacli.  Bircher  has  recently 
recorded  a  case  of  pedunculated  fibroma  of  the  stomach. 

Generally  situated  along  one  or  the  other  curvature,  they  are 
less  unusual  close  to  the  pylorus  than  at  the  cardia.  Arising  in 
the  muscular  tunics  of  the  stomach  wall,  they  grow  either  inward 


Myoma  of  the  Stomach. 


21 


or  outward,  projecting  as  a  rounded  more  or  less  nodular  mass, 
beneath  either  the  mucous  membrane  or  the  peritoneal  surface  of 
the  organ.  Being  at  first  attached  to  the  muscular  coat  by  a  ped- 
icle, this  may  become  extremely  attenuated,  as  in  Cernezzi's  case, 
and  finally  all  connection  between  the  tumor  and  the  muscular 
tunic  from  which  it  sprang  may  be  lost  (Virchow),  as  in  the  case 
of  the  analogous  tumors  of  the  uterus.  Gastric  myomata  are 
almost  invariably  single,  only  two  cases  of  multiple  myoma  being 
recorded    (Laboulbene,    Picenti)   if    we   except   certain  forms   of 


Fig.  25. — Fibroma  of  Posterior  Wall  of  Stomach.     One  Half  Natur.al  Size. 
{From  a  specimen  in  the  Museum  of  the  German  Hospital.) 


polypus  which  are  really  more  adenomatous  or  fibromatous  in 
character. 

Internal  myomata,  as  those  are  called  which  project  into  the 
cavity  of  the  stomach,  frequently  become  ulcerated,  and  give  rise 
to  haematemesis  or  melaena.  Fatal  hemorrhage  occurred  in  cases 
recorded  by  Kemke,  Miodowski  and  Niemeyer.  These  tumors 
are  seldom  very  large,  and  often  cannot  be  detected  through  the 
abdominal  wall.  External  myomata,  on  the  other  hand,  sometimes 
grow  to  an  immense  size,  the  tumor  in  Erlach's  patient  weighing 
5400  grammes,  and  reaching  in  the  case  of  Perls  and  Neelsen  deep 


2i6       Benign  Tumors  of  the  Stomach  and  Duodenum. 

into  the  pelvis,  and  weighing  6000  grammes.  The  gastric  origin 
of  such  large  tumors  frequently  is  not  recognized,  both  on  account 
of  their  position  in  the  abdomen,  and  because  of  secondary  attach- 
ments which  are  formed  to  other  structures.  Yet  adhesions  to  the 
anterior  abdominal  wall  are  unusual,  and  free  mobility  is  a  frequent 
characteristic;  especially  noteworthy  is  the  fact  that  the  uterus 
can  almost  always  be  excluded  as  the  seat  of  the  disease.  In  23 
of  the  reported  cases  the  tumor  is  recorded  as  being  internal,  in 
21  as  being  external,  and  in  i  the  growth  was  still  interstitial  in 
character  when  excised  (Poirier)  on  account  of  pylorospasm.  The 
age  of  25  patients  is  recorded;  19  were  over  40  years  of  age,  and 
13  of  these  were  more  than  50  years  old.  Of  the  27  patients  whose 
sex  is  stated,  11  were  males  and  t6  females. 

The  great  majority  of  gastric  myomata  are  strictly  benign,  but 
occasionally  they  are  malignant.  There  is  great  confusion  among 
pathologists  as  to  the  classification  of  these  malignant  varieties. 
In  a  great  many  myomata  there  have  been  noted  certain  areas  of 
oedema,  amounting  in  some  instances  to  myxomatous  degeneration. 
When  this  condition  is  pronounced,  the  term  myxomyoma  is  applied 
(Kemke).  Cysts  may  be  formed  thus,  or  as  the  result  of  hemorrhage 
into  the  tumor.  Certain  cases  have  been  reported  (Goullioud  and 
Mollard,  Goullioud,  Brodowski,  Hansemann,  Cohn)  in  which 
gastric  myomata,  with  more  or  less  myxomatous  degeneration, 
have  given  rise  to  metastases  in  the  liver,  peritoneum,  and  other 
structures;  and  in  these  metastatic  nodules  the  primary  growth 
was  in  large  part  reproduced,  the  cells  being  clearly  smooth  muscle 
cells,  with  an  admixture  of  myxomatous,  or  degenerated  cells. 
In  their  interpretation  of  the  "degenerated"  cells,  either  in  the 
primary  tumor  or  in  the  metastases,  pathologists  are  not  in  accord. 
They  were  long  regarded  as  sarcoma  cells,  and  the  i)rimary  tumor 
was  said  to  have  undergone  sarcomatous  degeneration.  But  some 
writers,  following  the  teaching  of  Bard  of  Lyons,  and  maintaining 
the  theory  of  the  specificity  of  tumor  cells,  claim  that  tumors  such 
as  those  just  described  are  pure  myomata,  and  that  the  so-called 
sarcoma  cells  are  nothing  more  than  immature  smooth  muscle 
cells.     These   authorities    (Parrot   and    P^erard;     Dcvic   and    Galla- 


Myoma  of  the  Stomach.  217 

vardin;  Giuliani)  name  such  a  tumor  Leiomyoma  mahgnum. 
Steiner,  Cernezzi,  and  others,  distinguish  between  sarcomatous 
myomata,  and  myosarcomata ;  the  latter  being  a  malignant  tumor 
ab  initio,  whereas  a  sarcomatous  myoma  is  one  which,  though  at 
first  benign,  finally  undergoes  malignant  degeneration.  Of  course 
there  is  theoretically  no  reason  why  the  connective  tissue  cells, 
present  in  a  fully  developed  myoma,  should  not,  as  described  by 
Steiner  (loc.  cit.,  S.  107-109),  eventually  become  sarcomatous, 
just  as  they  might  do  were  the  muscle  cells  themselves  normal, 
thus  forming  a  pure  sarcoma.  It  is  therefore  theoretically  possi- 
ble for  a  myoma  subsequently  to  become  sarcomatous  in  this  man- 
ner; but  such  a  tumor,  if  it  exist,  would  be  more  correctly  named 
a  sarcomatous  myoma,  or  a  myoma  sarcomatodes,  than  a  myosar- 
coma. x\nd  from  our  knowledge  of  pathological  processes  in 
general  it  appears  hardly  safe  to  conclude  that  muscle  cells,  even 
when  already  perverted  into  tumor  formation,  can  subsequently, 
by  metaplasia,  become  sarcoma  cells.  It  seems  to  us  more  rational 
to  look  upon  these  myomata  as  being  either  sarcomatous  tumors 
in  muscular  tissue  (myosarcoma  ab  origine),  or  as  being  examples 
of  leiomyoma  malignum,  as  described  by  Devic  and  Gallavardin 
and  by  Giuliani.  It  may  be  mentioned  in  passing  that  similar 
tumors  giving  muscular  metastases  have  been  described  in  connec- 
tion with  the  uterus. 

Further  confusion  is  added  to  the  subject  by  the  class  of  myo- 
mata in  which  angeiomatous  changes  exist.  Some  of  these  tumors 
are  undoubtedly  malignant,  and  are  classed  by  some  writers  as 
angeio-sarcomata,  and  by  others  as  endotheliomata  (von  Berg- 
mann;  Nichols).  Cyst  formation  is  frequent  in  these  angeio-myo- 
mata. 

Magnus-Alsleben  observed  post-mortem  five  patients  with  adeno- 
myoma  of  the  stomach,  and  he  concludes  that  in  these  tumors  the 
adenoma  is  the  primary  change,  and  that  it  is  later  crowded  out, 
so  to  speak,  by  the  myomatous  overgrowth.  Some  authors  have 
regarded  certain  instances  of  hyperemesis  lactantium  as  due  to  a 
congenital  myoma  of  the  pylorus.     (See  p.  134.) 

In  a  case   recorded  by  Monro   and  McLaren,  a   pedunculated 


2i8        Benign  Tumors  ot  the  Stomach  and  Duodenum. 

myoma  near  the  pylorus  was  present  in  a  stomach  on  whose  lesser 
curvature  was  a  carcinoma.  The  two  growths  had  no  connec- 
tion. 

Operative  treatment  should  be  undertaken  as  soon  as  a  gastric 
myoma  makes  its  appearance  known.  It  is  usually  possible  to 
remove  the  growth  by  resection  of  that  part  of  the  gastric  wall  from 
which  it  sprang;  but  occasionally  formal  excision  (partial  gastrec- 
tomy) is  required.  Operations  for  gastric  myomata  have  been 
performed  by : 

1.  Bircher  (]\Ied.  Klinik,  1908,  iv,  223,  Fall  2).    Resection  of  pedun- 

culated fibromyoma  from  anterior  wall  of  stomach.  Died  6 
days  later.     No  peritonitis.     Tumor  weighed  380  grammes. 

2.  Ehrenberg   (Perls  and  Neelsen:   Allgemein.    Pathol.,  Stuttgart, 

1886;  cited  by  Colin:  Inaug.  Dissert.,  Greifswald  1903). 
Resection  of  myoma  from  stomach.  Colin  does  not  mention 
result. 

3.  Eiselsberg  (Arch.  f.  klin.  Chir.,  1897,  liv,  599).     Resection  of 

immense  tumor  (myoma  sarcomatodes)  from  greater  curva- 
ture of  stomach.     Recovery. 

4.  Erlach  (Wien.  klin.  Woch.,  1895,  viii,  272).     Enucleation  of 

immense  myoma  from  between  layers  of  gastro-hepatic 
omentum,  and  from  lesser  curvature  of  stomach.     Recovery. 

5.  Goullioud  (Giuliani:   These  de  Lyon,  1904,  Obs.  II).     Partial 

gastrectomy  (Billroth  II)  for  leiomyoma  malignum  of  py- 
lorus, growing  between  layers  of  gastrocolic  omentum. 
Recovery. 

6.  Helfcrich    (Moser:    Deutsch.  med.  Woch.,   1903,  xxix,   157). 

Resection  of  part  of  lesser  curvature  of  stomach,  for  myoma 
sarcomatodes.     Died  from  peritonitis  on  fifth  day. 

7.  Herhold  (Deutsch.  med.  Woch.,  1898,  xxiv,  60).     Resection 

of  small  nodule  (myoma)  from  pylorus,  with  pyloroplasty. 
Recovery. 

8.  Laroyenne  (Goullioud  and  Alollard:   Lyon  Med.,  1896,  Ixxxii, 

257;  cited  by  Giuliani:  These  dc  Lyon,  igo.:!,  Obs.  I.). 
Enucleation  of  large  growth  from  gastrocolic  omentum. 
I^ied  in  6  hours  of  shock.  At  autopsy  the  primary  tumor 
fleiomyoma  malignum)  was  found  in  stomach  at  left  ex- 
tremity of  greater  cur\ature. 

9.  Moser  (Deutsch.  med.  Woch.,  1903,  xxix,  133).     Incision  for 

lefl  kidney  tumor.     Mass  found  to  spring  from  posterior 


Myoma  of  the  Stomach.  219 

wall  of  stomach.  Resection  of  posterior  gastric  wall  and 
part  of  pancreas.     Myosarcoma.     Recovery. 

10.  Nicoladoni  (Steiner:  Beitr.  z.  klin.  Chir.,  1898,  xxii,  i,  Fall  2). 

Resection  of  part  of  greater  curvature  and  transverse  colon 
for  fibromyoma.     Died  from  peritonitis  on  eighth  day. 

11.  Ochsner  (Yates:  Annals  of  Surgery,  1906,  ii,  599.     Case  i). 

Partial  resection  of  posterior  gastric  wall  for  pedunculated 
subserous  myoma.     Recovery. 

12.  Poirier  (Bull,   et   Mem.   de   la  Soc.  de  Chir.  de  Paris,  1902, 

xxviii,  273).  Resection  of  small  nodule  (myoma)  from 
pylorus  with  pyloroplasty.     Recovery. 

13.  Rupprecht    (Kunze:    Archiv.   f.   klin.    Chir.,    1890,.  xl,    756). 

Large  growth  (angeio-myoma)  growing  in  layers  of  gastro- 
colic omentum  excised  with  partial  resection  of  anterior 
gastric  wall  near  cardia,  from  which  region  the  tumor  sprang. 
Died  on  fifteenth  day  from  pneumonia. 

14.  Samter  (Deutsch.  med.  Woch.,  1904,  xxx,  914).     Partial  gas- 

trectomy (Billroth  II)  for  myoma  of  pylorus.     Recovery. 

REFERENCES. 

Myoma  and  Fibroma. 

v.  Bergmann:   cited  by   Borrmann:    Mitth.  a.   d.  Grenzgeb.  d.  Med.  u. 

Chir.,  1900,  vi,  543. 
Bircher:   Med.  Klinik,  1908,  iv,  223. 
Devic  and  Gallavardin:   Revue  de  Chir.,  1901,  xxiv,  282. 
Giuliani:  These  de  Lyon,  1904,  p.  39. 

Kolaczek:   Mitth.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1896,  i,  163. 
Morgagni:  De  Sed.  et   Caus.  Morb.,  Epist.  xix,  Art.  58.     Venetiis  1761, 

Tom.  I,  f.  191. 
Nichols:    "Tumors and  Tumor  Formation,"  in  Amer.  Practice  of  Surgery 

(Bryant  and  Buck),  New  York,  1906,  i,  339. 
Steiner:  Beitr.  z.  klin.  Chir.,  1898,  xxii,  i;  407. 
Tilger:  Virchow's  Arch.  f.  path.  Anat.,  1893,  cxxxiii,  183. 
Virchow:  Les  Tumeurs,  Paris  1871,  Tom.  Ill,  p.  320. 

Cases  of  Myoma. 

(Additional  to  Steiner's  tables.) 

Borrmann:  Mitth.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1900,  vi,  529. 
Bouveret:  Traite  d.  Malad.  de  I'Estomac,  Paris,  1893,  p.  482. 
Caminiti:  Polichnico,  Roma  1900,  vii,  Sez.  Chir.,  602. 
Capello  and  Capello:   Bull.  d.  r.   Accad.  med.   di.  Roma,  1898-99,  xxiv, 

321. 
Cernezzi:  II  Morgagni/Roma  1902,  xliv,  i,  143. 


220        Benign  Tumors  of  the  Stomach  and  Duodenum. 

Cohn:  Inaug.  Dissert.,  Greifswald  1903. 

Cutler:  Bost.  Med.  and  Surg.  Jour.,  1879,  c,  513. 

Ehrenberg:   see  Cohn,  loc.  cit.,  S.  24. 

Gouillioud:  see  Giuliani,  These  de  Lyon,  1904. 

Jean:  Bull,  et  Mem.  Soc.  Anat.  Paris,  1875,  1,  20. 

Kidd:  Trans.  Path.  Soc.  London,  1883-4,  xxxv,  196. 

Magnus- Alsleben:  Virchow's  Archiv  f.  path.  Anat.,  1903,  clxxiii,  156. 

Miodowski:  Virchow's  Arch.  f.  path.  Anat.,  1903,  clxxi,  156. 

Monro:   Glasgow  Med.  Jour.,  1901,  Iv,  115. 

Moser:  Deutsch.  med.  Woch.,  1903,  xxix,  133;   157. 

Noll:  Inaug.  Dissert.,  Wiirzberg  1901,  S.  27. 

Perls  and    Neelsen:    Allgem.    Pathol.,    Stuttgart    1886;    cited    by    Cohn, 

loc.  supra  cit. 
Poirier:  Bull,  et  Mem.  Soc.  Chir.  Paris,  1902,  xxviii,  273. 
Samter:  Deutsch.  med.  Woch.,  1904,  xxx,  914. 
Yates:  Annals  of  Surgery,  1906,  ii,  599. 


Adenoma  of  the  Stomach.  221 

Adenoma  and  Papilloma.  Gastric  adenomata  are  met  with 
in  two  forms:  (A)  Sessile  pedunculated  growths,  usually  single, 
and  practically  indistinguishable  from  mucous  papillomata;  (B) 
Polyadenomata,  or  mucous  polypi. 

(A)  The  former  variety,  which  is  usually  understood  when  the 
term  adenoma  is  employed,  projects  into  the  cavity  of  the  stomach, 
usually  in  the  pyloric  region,  in  the  form  of  a  rounded,  smooth  or 
slightly  lobulated  tumor,  evidently  composed  almost  solely  of  hyper- 
trophied  mucous  membrane.  When  solitary  such  tumors  have  been 
known  to  grow  to  the  size  of  an  apple,  or  even  to  that  of  a  fcetal 
head  at  term  (Chaput).  Sklifossowsky  recorded  under  the  name 
of  papilloma  of  the  stomach  two  cases  presenting  much  the  same 
macroscopic  and  microscopic  appearances  as  adenomata.  Mauler 
collected  all  cases  of  adeno-papillomata  recorded  up  to  1898. 
Hayem  called  attention  to  two  cases  of  adenoma  the  structure  of 
which  resembled  Brunner's  glands,  and  which  appeared  to  ori- 
ginate in  the  mucosa;  the  same  condition  has  been  since  observed 
by  other  pathologists.  These  tumors  usually  rapidly  penetrate 
the  muscularis  mucosas,  and  proliferate  in  the  submucous  tissues. 
The  more  usual  form  of  adenoma  is  strictly  a  mucous  growth. 
It  proliferates  above  the  muscularis  mucosa,  projecting  into  the 
cavity  of  the  stomach;  it  very  rarely  becomes  ulcerated,  unless 
malignant,  or  unless  it  proliferates  around  the  border  of  a  gastric 
ulcer.  It  is  usually  single,  but  several  may  be  present  in  different 
parts  of  the  stomach. 

When  pedunculated,  and  with  enough  fibrous  tissue  in  its  pedi- 
cle to  warrant  the  name  of  fibro-adenoma,  this  tumor  forms  one 
of  the  commonest  varieties  of  gastric  polypus.  An  intragastric 
polyp  may  occlude  the  pylorus,  thus  simulating  pyloric  stenosis 
from  other  and  more  frequent  causes;  and  when  easily  displaced 
may  produce  intermittent  dilatation  of  the  stomach,  as  in  a  remark- 
able case  reported  by  Bennett  (Figs.  26,  27).  In  one  case  quoted 
by  Fenwick  fatal  intussusception  of  the  duodenum  was  produced 
by  a  polyp  just  below  the  pylorus. 

In  general  it  may  be  said  that  a  fully  developed  gastric  polyp 
is  more  apt  to  produce  symptoms  than  is  any  other  form  of  benign 


222        Benign  Tumors  of  the  Stomach  and  Duodenum. 

gastric  tumor.  Multiple  polypi  were  found  by  Stevens  at  autopsy 
on  a  patient  who  had  been  subject  to  constant  epileptic  fits,  with 
an  aura  arising  in  the  stomach.  Such  cases  are  of  interest  in  con- 
nection with  the  subject  of  gastric  tetany.  McCosh  has  recorded 
a  case  of  gangrenous  gastritis  from  strangulation  of  a  polyp  in  the 
stomach. 

It  is  difficult  to  draw  a  boundary  line  between  adenomatous 
changes  frequently  encountered  in  the  stomach,  in  association  with 
unhealed  ulcers,  and  certain  histological  appearances  which  by 
some  pathologists  are  considered  pre-cancerous  in  nature.  For  a 
further  discussion  of  pre-cancerous  changes  the  reader  is  referred 
to  the   chapter  on  Gastric  Carcinoma  (p.  272).     The  relation  of 


Fig.   26.- 


-PoLYPUs  OF   Stomach   near 
Pylorus. 


Fig.  27. — Gastric  Polypus  near  Pylo- 
rus, Acting  as  Ball-valve. 


myoma  to  adenoma,  studied  by  Magnus-Alsleben,  has  already  been 
referred  to  at  p.  217. 

(B)  Polyadenomata,  or  mucous  polypi  of  the  stomach,  are 
usually  regarded  as  in  some  way  the  result  of  chronic  gastritis. 
They  are  as  a  rule  widely  distributed  over  the  interior  of  the  stom- 
ach, transforming  its  surface  into  a  pulpy  mass,  from  which  mucus 
can  readily  be  squeezed.  Each  polyp  is  more  or  less  distinct  from 
the  others,  and  none  are  larger  than  peas  or  small  cherries.  The 
centre  part,  or  stalk,  of  each  individual  tumor  is  composed  of 
fjljroLis  tissue,  containing  Ijlood  vessels  and  lym])liatics,  and  rep- 
resenting the  normal  submucosa.  Over  this  core  a  thickened 
hypcrtrophied  layer  of  smootli  muscular  tissue  is  found,  corrc- 


Gastric  Polypi.  223 

spending  to  the  muscularis  mucosae;  while  the  free  surface  of  the 
tumor,  frequently  cystic,  is  composed  of  hypertrophied  and  tor- 
tuous mucous  glands.  These  dilated  glands  are  said  to  resemble 
closely  the  uriniferous  tubules  in  the  cortex  of  the  kidney.  Ac- 
cording to  Menetrier,  the  cysts  result  from  involvement  of  the 
ducts  of  the  glands;  whereas  when  the  fundi  of  the  glands  are 
chiefly  affected,  the  cysts  are  few  in  number  and  of  small  size. 
These  mucous  polypi  are  freely  movable  over  the  subjacent  tissues, 
and  the  neighbouring  lymphatic  nodes  are  never  affected.  Yet 
Norman  has  recorded  a  case  of  polyadenomata,  apparently  belong- 
ing to  this  class,  in  which  the  change  was  not  considered  malignant 
although  the  glandular  tissue  had  broken  through  the  muscularis 
mucosas  and  proliferated  in  the  submucous  tissue.  Bier  has  recently 
done  gastro-jejunostomy  for  a  similar  affection  (diffuse  polyposis), 
the  patient  being  reported  as  improved  18  months  later,  although 
microscopical  examination  of  a  portion  of  the  gastric  mucosa  had 
shown  "early  malignant  changes." 

Menetrier  also  describes  a  form  of  mucous  polypus  which  he 
calls  ^' polyadenome  en  nappe,"  in  which  condition  the  adenoma- 
tous formation  is  not  confined  to  any  circumscribed  area  or  areas, 
with  the  formation  of  distinct  polypi;  but  the  hypertrophy  and 
hyperplasia  affect  simultaneously  all  the  glands  over  a  fairly  large 
area,  or  even  through  the  whole  stomach. 

All  these  adenomatous  tumors  (the  adenoma  proper  and  the 
mucous  polypi)  have  these  distinguishing  histological  features: 
they  are  separated  on  the  one  hand  from  simple  inflammatory  or 
hypertrophic  changes  by  the  fact  that  although  there  is  hyperplasia 
of  the  glandular  structures,  yet  the  pepsin  or  oxyntic  cells  present 
in  normal  glands  fail  to  be  reproduced  in  the  adenomatous  neo- 
plasms; and,  on  the  other  hand,  they  are  distinguishable  from 
adeno-carcinoma  by  the  fact  that  nowhere  may  the  epithelial  cells 
of  the  adenoma  be  found  to  have  penetrated  the  muscularis  mucosae 
or  to  be  deprived  of  their  normal  basement  membrane. 

Symptoms. — Unless  pedunculated,  adenoma  of  the  stomach 
is  characterized  by  no  very  well  defined  symptoms.  In  cases 
recorded  by  Gourrand,  and  by  Quain  and  Beardsley  a  gastric 


224        Benign  Tumors  of  the  Stomach  and  Duodenum. 

polypus  was  vomited.  In  the  case  of  mucous  polypi  the  patient 
may  complain  of  constant  gastric  discomfort,  and  nausea  may  be 
a  prominent  feature  of  the  case.  This  condition  has  been  suspected 
during  life,  and  the  suspicion  confirmed  at  autopsy,  in  the  case 
of  patients  who  have  suffered  from  a  sensation  of  worms  crawling 
around  the  stomach. 

A  correct  diagnosis  can  rarely  be  made;  it  is  sometimes  possible, 
however,  to  determine  the  presence  of  a  benign  tumor.  In  other 
cases  an  exploratory  operation  is  undertaken  for  the  symptoms 
of  pyloric  stenosis,  or  even  of  prolonged  gastric  indigestion.  Usu- 
ally it  has  been  possible  to  excise  the  tumor  with  or  without  partial 
resection  of  the  gastric  wall.  Many  more  such  operations  are 
recorded  for  adenomata  which  showed  malignant  changes  than 
for  those  which  were  undoubtedly  benign.  Operations  for  the 
removal  of  gastric  adenomata  have  been  recorded  by: 

1.  Lange  (N.  Y.  Med.  Jour.,  1892,  Iv,  584).     Partial  resection  of 

anterior  gastric  wall  for  ulcerated  benign  adenoma.  Re- 
covery. 

2.  Chaput  (Bull,  et  Mem.  de   la  Soc.  de  Chir.  de  Paris,  1895,  Ixx, 

534).  Gastrotomy:  partial  resection  of  posterior  gastric 
wall  for   immense   fibroadenomatous   polypus.     Recovery. 

3.  Lyman  (Annals  of  Surgery,  1896,  ii,  310).      Gastrotomy:    am- 

putation of  pedunculated  adeno-carcinoma  from  posterior 
wall  of  stomach.     Death  in  one  month. 

4.  Bennett  (Brit.  Med.  Jour.,  1900,  i,  241).     Gastrotomy.     Papil- 

lomatous polyp  amputated  from  pyloric  region.     Recovery. 

5.  Robson  and  Moynihan  (Dis.  of  Stomach,  N.  Y.,  1904,  p.  75). 

Sessile  adenoma  excised  from  pylorus,  with  pyloroplasty. 
Recovery. 

6.  Hinds  (Robson  and  Moynihan:  Surg.  Treat.  Dis.  of  Stomach, 

N.  Y.,  1904,  p.  76).  Gastrotomy;  resection  of  polypoid 
adenoma  from  posterior  wall  of  pylorus.  Recovery.  Gas- 
tro-jejunostomy  18  months  after,  with  death  from  exhaustion 
in  48  hours. 

REFERENCES. 

Bennett:  Brit.  Med.  Jour.,  1900,  i,  241. 

Bier:    Sec  Wcji;clc,  Mitth.  a.  d.  Grcnzgeb.  d.  Med.  u.  Chir.,  1908,  xix,  53. 

Chaput:  Bull,  et  Mem.  Soc.  Anat.  Paris,  1895,  Ix.x,  534. 


Adenoma  of  the  Stomach.  225 

Fenwick:  Cancer  and  other  Tumors  of  the  Stomach,  Phila.,  1903,  p.  310. 

Gourrand:   Jour,  de  Med.,  Chir.,  Pharm.,  Paris,  1790,  iv,  366. 

Hayem:  Bull,  et  Mem.  Soc.  d.  Hopitaux,  Paris,  1895,  xii,  327. 

Mauler:  Inaug.  Dissert.,  Geneve,  1898. 

McCosh:  Annals  of  Surgery,  1900,  ii,  630. 

Menetrier:   "Les  Tumeurs."     Traite  de  Path.  Gen.   (Bouchard),   Paris, 

1899,  iii,  844. 
Norman:  Dubl.  Jour.  Med.  Sc,  1893,  xcv,  346. 
Quain  and  Beardsley:   Trans.  Path.  Soc.  London,  1856-7,  viii,  219. 
Sklifossowsky:   Arch.  f.  path.  Anat.,  1898,  cliii,  130. 
Stevens:   Glasgow  Med.  Jour.,  1896,  xlv,  422. 


15 


226      Benign  Tumors  of  the  Stomach   and   Duodenum. 

Lipoma.  Lipoma  of  tlie  stomach  is  referred  to  by  Virchow. 
These  tumors  may  arise  in  either  the  submucous  or  the  suberous 
adipose  tissue.  According  to  Cruveilhier,  small  lipomata,  the 
size  of  peas  or  beans,  are  not  unusual.  In  such  cases  the  masses 
of  fat  are  probably  not  heterologous,  but  merely  a  localized  increase 
in  the  amount  of  fat  normally  present.  Cohn  has  recently  reported 
finding  at  autopsy  on  a  patient  with  malignant  gastric  myoma,  a 
small  submucous  lipoma  at  the  pylorus.  It  is  to  the  larger  tumors, 
which  may  more  justly  be  recognized  as  neoplastic  in  character, 
that  this  paragraph  has  special  reference.  Hartmann  in  discussing 
in  1905  a  case  of  submucous  lipoma  of  the  pyloric  antrum,  found 
at  autopsy  by  Benaky,  of  Smyrna,  says  that  the  only  cases  reported 
up  to  that  time  were  the  following: 

1.  Cruveilhier;    Submucous  lipoma. 

2.  Virchow;   Submucous  lipoma. 

3.  Tilger;    Submucous  lipoma. 

4.  Tilger;    Submucous  lipoma. 

5.  Fen  wick;    Submucous  lipoma. 

To  these  should  be  added  four  other  cases  (all  subserous)  of 
gastric  lipoma:  two  recorded  by  Russdorf,  and  one  each  reported 
by  Orth  and  Murray.  Fischer  has  reported  a  case  of  fibro-lipoma 
of  the  stomach  in  a  woman  aged  37  years,  ^hich  had  caused  pain 
in  the  left  epigastric  region  for  about  a  month.  An  epigastric 
hernia  developed,  but  there  was  no  vomiting,  no  hemorrhage  and 
no  indigestion.  The  left  rectus  was  rigid,  and  a  diagnosis  was 
made  of  recent  inflammatory  processes  in  a  tumor  of  long  standing, 
though  no  tumor  was  palpaljle.  Operation  showed  the  hernia 
to  be  an  epi])locele,  and  the  tumor  was  found  on  the  lesser  curva- 
ture of  the  stomach,  not  involving  the  mucous  membrane.  It 
wa.s  successfully  resected;  and  microscopical  examination  showed 
a  fibro-lipoma,  with  acute  inflammation  and  hemorrhage  into  the 
substance  of  the  tumor.  The  convalescence  was  delayed  by  five 
attacks  of  tetany  on  the  seventeenth  day  after  o])eration. 

In  none  of  these  jjatients,  cxcej^t  Fischer's,  was  operation  under 
taken;    Ijul  as  all    the    tumors  were   easily   enucleated    at  autojisy, 
it  would  be  j)erfc(tly  projjcr  to    attem])t    their    removal    by   gastro- 
tomy,  should  their  jjresence  be  discovered  (hiring  life. 


Lipoma  of  the  Stomach.  227 


REFERENCES. 

Cohn:   Inaug.  Dissert.,  Greifswald,  1903.     Fall  i. 

Cruveilhier:    Anat.   Pathol,   Paris    1835-42,   Tom.    ii,   XXXe  Livr.,   PI. 

II.  Consid.  Gen.,  p.  3. 
Fenwick:    Cancer   and    other  Tumors  of    the  Stomach,  Phila.,  1903,  p 

35°- 
Fischer:    Annals  of  Surgery,  1905,  xlii,    583;     also,    Arch.  f.    klin.    Chir., 

1905,  Ixxvii,  845. 
Hartmann:   Bull,  et  Mem.  Soc.  Chir.  Paris,  1905,  xxxi,  817. 
Murray:   Trans.  Path.  Soc.  London,  1888-9,  ^^)  7^- 
Orth:   Lehrb.  d.  Path.  Anat,  Berlin,  1887,  i,  717. 
Russdorf:  Deutsche  Klinik,  1867,  xix,  115. 
Tilger:  Arch.  f.  path.  Anat.,  1893,  cxxxiii,  183. 
Virchow:   Path,  des  Tumeurs,  Paris,  1867,  i,  369. 


228      Benign  Tumors  of  the  Stomach  and  Duodenum. 

Cysts.  Cysts  are  found  in  the  stomach  either  as  retention 
cysts  of  the  mucous  glands,  or  as  the  result  of  traumatism  or  the 
degeneration  of  other  forms  of  tumor.  There  are  also  on  record  one 
case  of  dermoid  cyst  and  a  few  cases  of  hydatid  cysts.  The  der- 
moid cyst  (Ruyschius)  contained  hair,  teeth  attached  loosely  to  bone, 
and  other  matters  almost  too  wonderful  for  belief.  Three  of  the 
hydatid  cysts  were  found  at  autopsy;  two  (Bochlendorf ;  Barton) 
involved  the  stomach  in  the  course  of  their  developement,  but  did 
not  originate  in  the  gastric  wall;  while  in  the  case  recorded  by 
Castellvi  y  Pallares  the  gastric  w^all  seems  to  have  been  the  primary 
seat  of  growth.  A  fourth  case  of  hydatid  cyst  has  been  recorded  by 
Hartmann;  at  the  operation,  by  Dujarier,  the  cyst  was  found  to  have 
developed  between  the  mucous  and  muscular  coats  of  the  stomach ;  it 
was  successfully  excised.  Tufher  has  operated  on  a  patient  with  hy- 
datid cyst  developing  in  the  gastro-hepatic  omentum,  and  thus  simu- 
lating a  tumor  of  the  lesser  curvature  of  the  stomach. 

Numerous  small  cysts  of  the  mucosa  are  frequently  seen  in 
certain  forms  of  gastritis.  They  are  true  retention  cysts,  the 
inflammation  obliterating  the  glandular  orifices — a  pathological 
change  seen  to  an  even  more  marked  degree  in  the  developement 
of  adenomata.  These  small  retention  cysts  have  practically  no 
surgical   interest,    unless   in   connection   with  polyps  or  adenomata. 

Traumatic  cysts  of  the  stomach  are  very  rare.  Zicgler  and 
Chutro  have  each  successfully  operated  on  such  a  case,  x^s  shown 
in  Chutro's  valuable  contribution  to  the  literature  of  gastric  cysts, 
the  history  is  that  of  severe  traumatism  to  the  epigastric  and  left 
hypochondriac  regions.  Shock,  pain,  and  persistent  vomiting, 
but  without  evidences  of  peritoneal  infection,  arc  the  immediate 
symptoms.  A  little  blood  may  be  vomited  or  passed  from  the 
bowels.  After  a  few  days  or  weeks,  the  more  acute  symptoms 
subside,  though  vomiting  may  persist;  and  the  physical  signs  are 
more  accurately  localized  to  the  stomach.  A  semi-fluctuating 
tumor  may  form.  It  is  difficult  to  distinguish  this  from  an  encysted 
peritonitis;  but  the  absence  of  suppurative  signs  will  be  an  im- 
portant clue.  No  time  should  now  be  lost  in  evacuating  the  con- 
tents of  the   cyst   by  laparotomy;    suture  of   the   cy<i  to  the  parietal 


Cysts  of  the  Stomach.  229 

peritoneum  and  drainage  effected  a  cure  in  both  patients.  The 
cyst  forms  as  the  result  of  hemorrhage  into  the  subserous  (Zeigler) 
or  submucous  tissues  (Chutro).,  aided  perhaps  by  the  effusion  of 
gastric  juice  from  the  deeper  portions  of  the  mucous  membrane, 
which  in  Chutro's  patient  was  intact.  The  cyst,  at  first  hemor- 
rhagic, soon  becomes  serous  or  sero-purulent  in  character.  The 
dangers  of  delay  in  operating  are:  (i)  Infection  of  the  cyst  from 
stomach  contents;  (2)  intraperitoneal  rupture  of  the  cyst,  causing 
peritonitis;  (3)  rupture  of  the  cyst  into  the  stomach,  creating  a 
septic  perigastric  abscess.  Any  of  these  events  may  be  responsible 
for  death  in  patients  with  gastric  cysts  not  of  traumatic  origin. 

More  frequent  are  cysts  which  occur  as  the  result  of  degenera- 
tion of  other  forms  of  tumors.  According  to  Virchow,  cyst  forma- 
tion is  a  not  unusual  termination  of  fatty  tumors;  audit  is  certainly 
true  that  most  of  the  gastric  cysts  reported  have  contained  fluid 
resembling  disintegrated  blood  clot  and  fat.  The  large  cyst  sur- 
rounding the  anterior  wall  of  the  stomach,  found  post-mortem  by 
Read,  appears  to  have  originated  as  a  submucous  lipoma  which 
afterward  underwent  malignant  change ;  while  the  remarkable  case  re- 
corded by  Hutchinson  and  Sloane  in  which  a  walnut  sized  cyst  was 
found  at  autopsy,  being  both  subserous  and  submucous,  and  its  two 
sacs  communicating  by  a  narrow  orifice  in  the  muscular  tunic,  was 
possibly  also  of  the  same  derivation,  the  contents  being  pinkish,  thick, 
opaque,  and  glittering  with  plates  of  cholesterine.  Albers  observed  a 
cyst  of  the  lesser  curvature  at  autopsy  on  a  child.  Hebb  and  Finnel 
have  each  recorded  a  gastric  cyst  which  Fenwick  classes  as  serous. 
In  Hebb's  case  the  cyst  was  lined  with  epithelioid  cells,  and  m.ay 
therefore  have  been  lymphangeiomatous  in  origin.  Finnel's 
patient  also  had  carcinoma  of  the  pylorus.  Cases  in  which  a 
probable  hemorrhagic  origin  can  be  traced  have  been  reported  by 
Rendu,  by  Gallois,  Hontang  and  Leflaive  and  by  Anderson.  Some 
of  these  so-called  hemorrhagic  cysts  may  have  been  due  to  forgotten 
injuries,  but  it  is  probable  that  most  of  them  were  degenerations 
of  pre-existing  tumors.  In  the  case  recorded  by  Fenwick  this 
origin  is  more  certain  in  view  of  the  lymphangeiomatous  structure 
which  is  mentioned.     A    true   lymphangeiomatous    cyst    has    been 


230        Benign  Tumors  of  the  Stomach  and  Duodenum. 

reported  by  Engel-Reimers,  in  whose  patient  the  presence  of  an 
intensely  deforming  scar  near  the  lesser  curvature  made  it  seem 
likely  that  the  subserous  cyst  of  lymphangeiomatous  structure 
was  not  a  true  neoplasm,  but  merely  a  retention  cyst  due  to  the 
obstruction  to  the  lymph  channels  by  the  cicatrix  already  described. 

There  remains  to  be  discussed  the  extremely  rare  affection 
"Gaseous  cysts."  This  disease,  well  known  to  the  veterinarian 
from  its  frequent  occurrence  in  swine,  has  been  studied  in  its  human 
relation  by  Hahn  and  by  Holstein.  According  to  these  authors  the 
disease  was  first  noted  at  autopsy,  in  1754,  by  Duvernoy.  Cloquet 
in  1820  reported  a  case  of  gaseous  cysts  (submucous  and  subserous) 
of  the  stomach  and  intestines.  He  had  also  observed  it  in  the  hog. 
Mayer  in  1825  determined  that  the  gas  in  these  cysts  was  com- 
posed of  oxygen  and  nitrogen,  15.44  parts  of  the  former  to  84.56 
parts  of  the  latter.  Gaseous  cysts  of  the  vagina  and  of  the  bladder 
have  also  been  noted.  Dupraz  in  1897  found  that  the  gaseous 
cysts  of  a  stomach  studied  by  him  were  dilatations  of  the  lymph 
spaces,  and  that  they  were  accompanied  by  chronic  lymphangeitis. 
There  is  no  doubt  as  to  the  bacterial  origin  of  some  of  these  cysts, 
but  different  micro-organisms  have  been  found  by  different  obser\'ers 
Hahn,  Jaboulay,  and  Vallas  have  operated  on  patients  with  gas- 
eous cysts.  Finney  has  recently  published  a  paper  based  on  a  study 
of  19  collected  cases  of  gaseous  cysts  of  the  gastro- intestinal  tract. 

Operative  treatment    has    been    undertaken   in    the    following 
cases  of  gastric  cysts. 

1.  Rendu:    Hemorrhagic  cyst    aspirated    three    times,    and    finally 

drained  by  a  large  canula.     Death  from  peritonitis. 

2.  Gallois,  Hontang    and    Leflaive:     Hemorrhagic    cyst    punctured 

twice.     Death  after  many  months  from  intraperitoneal  rup- 
ture of  the  cyst. 

3.  Zeigler:   Traumatic  cyst  opened  and  drained.     Recovery. 

4.  Winands:    Intestine  yamctured  for  obstruction.     True  conchtion 

found  five  years  later  at  autopsy. 

5.  Anderson:     Hemorrhagic    cyst    opened    and  drained.     Death    in 

24  hours  of  exhaustion. 

6.  Hahn:    Multiple    gaseous    cysts.     Excision    of    those    that  were 

pedunculated,  and  ])un(lure  of  others.     Recovery. 


Cysts  of  the  Stomach.  231 

7.  Jaboulay  explored  abdomen   of  patient   with  gaseous   cysts,  did 

pylorodiosis  by  Hahn's  method,  and,  beheving  the  cysts 
were  due  to  some  low  grade  inflammatory  process  analogous 
to  tuberculosis,  closed  abdomen  without  drainage  and  with- 
out interfering  with  cysts.     Recovery. 

8.  Vallas:     Exploratory    operation    for    intestinal    obstruction  with 

peritonitis.     No  cause  found.     Abdomen    drained.     Death. 
At  autopsy   innumerable  subserous  and  submucous  gaseous 
cysts    of    stomach    and    intestines.      The    submucous    cysts 
had  in  some  places  caused  intestinal  obstruction, 
g.  Chutro:   Traumatic  cyst  opened  and  drained.     Recovery. 

REFERENCES. 

Albers:  Erlauterungen  z.  path.  Anat.,  1862,  Abth.  iv,  Bd.  i,  S.  151. 

Anderson:   Brit.  Med.  Jour.,  i8g8,  i,  426. 

Barton:    California  Med.  and  Surg.  Reporter,  1906,  ii,  689. 

Bochlendorf :  cited  by  Fenwick,  loc.  infra  cit.,  p.  336. 

Castellvi  y  Pallares:   cited  by  Fenwick,  loc.  infra  cit.,  p.  336. 

Chutro:    Revista  de  la  Soc.  Med.  Argentina,  Buenos  Aires  1905,  xiii, 

171- 
Engel-Reimers :   Deutsch.  Arch.  f.  klin.  Med.,  1879,  xxiii,  632. 
Fenwick :    Cancer  and   Other   Tumors    of    the    Stomach,    Phila.,    1903, 

p.  340. 
Finnel:  N.  Y.  Med.  Jour.,  1874,  xx,  640. 
Finney:  Jour.  Amer.  Med.  Assoc,  1908,  ii,  1291. 
Gallois,  Hontang  and  Leflaive:    Bull,   et  Mem.   Soc.  Anat.   Paris,    1884, 

lix,  556. 
Hahn:   Deutsch.  med.  Woch.,  1899,  xxv,  657. 
Hartmann:   Revue  de  chir.,  1908,  xxxviii,  159. 
Hebb:  Trans.  Path.  Soc.  London,  1897-8,  xlix,  94. 
Holstein:   Semaine  Med.,  1899,  xix,  419. 

Hutchinson  and  Sloan:  Trans.  Path.  Soc.  London,  1856-7,  viii,  218. 
Jaboulay:  Lyon  Med.,  1901,  xcvi,  753. 
Read:  N.  Y.  Med.  Record,  1882,  i,  628. 
Rendu:   Bull,  et  Mem.  Soc.  Anat.  Paris,  1880,  Iv,  120. 
Ruyschius:    Adversaria    Anat.,    Decas    Tertia,    I,     "De    Atheromate," 

p.  2;   in  "Opera  Omnia,"  Amstelodami  1737. 
Tuffier:   Revue  de  Chir.,  1908,  xxxviii,  160. 
Vallas:   Lyon  Med.,  1901,  xcvi,  958. 
Winands:   Beitr.  z.  path. .Anat.,  1895,  xvii,  38. 
Zeigler:   Munch,  med.  Woch.,  1894,  xh,  103. 


232      Benign  Tumors  of  the  Stomach  and  Duodenum, 

Osteoma.  That  it  is  not  impossible  for  a  gastric  tumor  to 
undergo  osteoid  transformation  is  proved  by  the  unique  case  re- 
ported by  Webster.  He  found  at  autopsy  on  a  patient  who  had 
died  with  symptoms  of  intestinal  obstruction,  that  the  pylorus  was 
plugged  as  with  a  cork  by  a  cartilaginous  tumor,  with  numerous 
spiculae  of  bone,  which  was  adherent  to  the  gastric  wall  near  the 
pyloric  orifice. 

REFERENCE. 

Webster:  London  Med.  and  Phys.  Jour.,  1827,  n.  s.,  ii,  433. 

Concretions  have  been  found  in  the  stomach  occasionally. 
They  are  generally  due  to  the  long  continued  use  of  mineral  sub- 
stances (bismuth,  etc.)  as  medicines.  Fen  wick  refers  to  four 
instances  in  which  such  concretions  were  composed  of  shellac  or 
varnish.  In  the  museum  of  the  Academy  of  Natural  Sciences  of 
Philadelphia  there  is  a  remarkable  specimen  of  a  large  gastrolith 
from  a  horse,  deposited  by  Dr.  John  Ashhurst,  Jr. 

REFERENCE. 
Fenwick:   Cancer  and  Other  Tumours  of  the    Stomach,   London,    1902, 
P-  325- 

Angeioma.  Stockis,  at  the  autopsy  on  a  twelve  day  old 
infant,  who  died  in  convulsions  after  profuse  hasmatemesis  and 
melcena,  found  a  capillary  angeioma,  in  the  submucous  and  muscu- 
lar tissue  of  the  stomach  near  the  cardia,  which  was  proved  to  be 
the  source  of  the  hemorrhage.  In  connection  with  sarcoma  and 
myoma  angeiomatous  changes  are  not  unusual. 

REFERENCES. 

Lammers:     "Angeioma    Ventriculi    Simplex,"  Inaug.    Dissert.,    Greifs- 

wald,  1893.     (This  has  not  been  accessible.) 
Stockis:  Annales  de  la  Soc.  Mdd.-Leg.  de  Beige,  1905,  xvi,  61. 

Lymphadenoma.  Gilly  collected  in  1886  51  cases  of 
gastro- intestinal  lym])hadcnoma,  the  stomach  being  involved  in 
14  instances.      A  few  cases  have  been  recorded  since  (Pitt).       In 


Lymphadenoma  of  the  Stomach.  233 

all  known  cases,  lymphomatous  growths  have  been  observed  in 
other  parts  of  the  body  as  well  — in  the  spleen,  lymph  nodes,  bones, 
pharynx,  or  intestines.  In  all  cases  of  gastric  lymphadenoma, 
the  intestines  were  also  involved.  This  affection  arises  either 
in  the  subserous  or  submucous  lymphatic  tissues  of  the  stomach. 
In  the  submucous  tissues  it  exists  either  as  a  localized  or  diffused 
form,  usually  manifesting  itself  on  the  surface  of  the  stomach  by 
a  polypoid  condition  of  the  mucosa.  Ulceration  is  more  usual 
in  the  circumscribed  form.  The  tumors  which  arise  in  the  sub- 
mucous tissues  rarely  cause  obstruction,  but  those  commencing 
in  the  subserous  tissue,  and  which  are  usually  diffuse,  frequently 
penetrate,  paralyse,  and  ultimately  destroy  the  muscular  coat, 
producing  dilatation  of  the  stomach  and  consequent  stagnation  of 
food.  In  some  cases  it  appears  to  have  been  demonstrated  that 
the  disease  originated  in  the  neighbouring  mesenteric  lymph  nodes, 
and  subsequently  involved  the  subserous  lymphatic  structures  of 
the  stomach. 

REFERENCES. 

Gilly:   These  de  Paris,    1886;    cited  by  Bouveret,   Traite  d.   Malad.  de 

I'Estomac.     Paris  1893,  p.  483. 
Pitt:  Trans.  Path.  Soc.  London,  1888-9,  ^1j  ^o- 


234      Benign  Tumors  of  the  Stomach  and  Duodenum. 

Plastic  Linitis.  This  term  was  used  by  Brinton  to  describe 
a  disease  which  had  been  previously  studied,  but  had  not  been  named, 
by  AndraL  It  is  an  affection  characterized  patholgically  as  a 
diffuse  sclerosis  of  the  stomach,  involving  especially  the  submucous 
tissues,  and  accompanied  by  marked  thickening  of  the  gastric 
walls,  and  by  a  diminution  in  the  capacity  of  the  stomach.  The 
process  usually  commences  in  the  pyloric  region,  and  gradually 
spreads,  without  affecting  the  mucous  membrane,  until  the  entire 
wall  of  the  stomach  becomes  thickened  and  rigid,  and  its  lumen 
much  diminished  in  size.  There  have  been  many  other  synony- 
mous terms  employed  to  describe  the  same  condition.  Among 
the  best  known  are :  Cirrhosis  of  the  Stomach ;  Zuckergussmagen ; 
Submucous  Sclerosis;  Endogastritis  Obliterans;  Magenschrump- 
fung;  etc.  The  causes  to  which  this  pathological  change  have 
been  attributed  are  many.  Carcinoma  and  syphilis  sometimes 
produce  a  profuse  gastric  infiltration  which  even  microscopically 
is  distinguishable  from  this  affection  only  with  the  greatest  difficulty. 
Some  cases  of  hyperemesis  lactantium  seem  to  be  caused  by  an 
identical  submucous  sclerosis.  Plastic  linitis  is  usually  regarded 
as  benign,  and  is  considered  by  most  of  those  who  have  ^Wen  most 
attention  to  the  subject,  a  special  disease  entity.  The  best  articles 
recently  published  are  those  of  Brissaud,  of  Jonnesco  and  Grossman, 
and  of  Kurt  von  Sury.  The  latter  concludes  that  cirrhosis  of 
the  stomach  is  due  to  the  same  cause  as  polyserositis,  namely 
chronic  passive  hyperaemia  from  cardiac  insufi^ciency.  Jonnesco 
and  Grossman  believe  that  it  is  simply  a  chronic  inflammatory 
change,  and  in  no  way  neoplastic  in  character.  Histologically  it 
appears  to  be  nearly  related  to  tlie  lym})hadenomatous  changes 
just  described.  Its  connection  with  chronic  obstruction  of  the 
efferent  lymph  vessels  of  I  lie  stomach  does  not  appear  to  have 
received  suHicient  attention.  Its  relations  Avith  endothelioma  and 
sarcoma  are  not  clear. 

By  microscopical  examination  it  is  sometimes  impossible  to 
say  whether  the  epithelioid  cell  nests  which  infiltrate  the  submu- 
cous and  muscular  tissues  are  really  cpitheHal  in  derivation  (car- 
cinoma), or  due  to    ])rolifcration    of   ])reviousIy   exist inti;  enrlothelial 


Plastic  Linitis.  235 

cells  lining  the  lymph  channels  which  normally  exist  in  these  situa- 
tions. (See  Jaboulay's  case  of  subtotal  gastrectomy  for  an  infiltrating 
growth  thought  by  Gayet  and  Patel  to  be  epitheliomatous.) 

As  the  question  of  the  pathology  of  this  affection  is  still  suh  judice, 
it  is  probably  safer  at  present  to  regard  it  as  a  pathological  change 
which  may  arise  in  several  different  diseases — carcinoma,  syphilis, 
pericardial  adhesions,  lymphatic  obstruction,  etc. 


f. 


\ 
I 


Fig.  28. — Total  Contraction  of  the  Stomach  (Magenschrumpfxjng)  from 
Plastic  Linitis.  Natural  Size.  {From  a  specimen  in  the  Museum  of  the 
German  Hospital.) 


Treatment  must  usually  be  palliative.  Should  the  change  be 
recognized  early  enough,  partial  gastrectomy  should  be  attempted. 
In  a  somewhat  similar  case  Sheldon  did  gastro-jejunostomy,  and 
reported  his  patient  in  good  health  three  years  and  a  half  later. 
In  cases  of  pyloric  stenosis,  such  as  those  recently  reported  by 
Mansell  Moullin,  where  no  evidence  of  ulcer,  past  or  present,  could 
be  detected,  but  where  the  obstruction  appeared  to  be  caused  by 
fibroid  thickening,    Finney^s    operation   of   pyloroplasty  may  bring 


236        Benign  Tumors  of  the  Stomach  and  Duodenum. 

relief,  as  it  did  in  the  seven  patients  reported  by  Moullin.  If  the 
disease  has  progressed  so  far  as  practically  to  obliterate  the  cavity 
of  the  entire  stomach,  duodcnostomy  should  be  done;  or  if  the 
disease  has  invaded  the  duodenum,  jejunostomy  may  be  the  last 
resort.  This  operation  was  adopted  in  one  case  of  this  disease  by 
V.  Eiselsberg,  with  gratifying  result,  the  patient  still  using  the  fistula 
with  comfort  five  years  after  the  operation. 

Jonnesco  and  Grossman  refer  to  operations  of  pylorectomy  for 
this  condition  recorded  by  Delbet  and  Brissaud,  in  1900,  and  by 
Chaput  and  (Etinger  in  igoi.  They  state  that  gastro-jejunostomy 
was  done  by  Chaput  and  Pilliet  in  1896,  and  by  Roux  of  Lausanne 
in  1904.  In  their  own  patient  gastrostomy  was  done;  as  the  cavity 
of  the  stomach  was  nearly  obliterated,  and  as  the  pylorus  would 
not  admit  the  passage  of  a  tube  into  the  duodenum,  this  first  opera- 
tion was  followed  after  four  days,  when  the  patient's  strength  had 
somewhat  increased,  by  a  jejunostomy  in  Y.  But  the  patient 
preferred  to  swallow  his  food;  and  as  the  gastrostomy  wound  be- 
came very  much  inflamed  from  the  escape  of  the  ingested  food 
which  could  not  pass  the  pylorus,  an  attempt  was  made  about 
four  weeks  later  to  close  the  gastric  fistula.  Unfortunately  the 
patient  died  of  exhaustion  two  days  later.  The  result  of  this  case 
shows,  as  Jonnesco  and  Grossman  affirm,  that  jejunostomy  is 
better  as  a  primary  operation  than  gastrostomy.  Leersum  treated 
a  patient  with  " endogastritis  obliterans"  by  pyloroplasty;  but  as 
improvement  did  not  continue,  he  performed  total  gastrectomy 
three  weeks  later,  doing  an  oesophago-jcjunal  anastomosis.  The 
patient  recovered  and  gained  twenty  pounds  in  weight.  Morone  has 
recorded  a  case  of  plastic  linitis,  clearly  epitheliomatous  in  character, 
in  which  Tansini  did  partial  gastrectomy;  the  patient  was  in  good 
health  14  months  later.  One  patient  with  diffuse  fibrosis  of  the 
stomach,  clinically  resembling  plastic  linitis,  has  been  operatcfl  on 
by  Dr.  Deaver  at  the  German  Hospital: 

Case.  Frank  K.,  aged  46  years.  Two  uncles  died  of  pulmon- 
ary tuljcrculosis.  When  22  years  of  age  the  ])atient  was  accidentally 
inoculated  with  syphilis,  developing  a  chancre  on  the  thumb.  Had 
anti-syphilitic   treatment  for  2  years.     In   1903,  three  years  before 


Plastic  Linitls.  237 

admission  to  the  German  Hospital,  he  had  an  attack  of  pyelitis, 
after  the  passage  of  a  urethral  sound.  Following  this  illness  he 
suffered  from  acute  gastritis,  having  hiccoughed  for  11  days.  For 
the  last  2  years  has  suffered  from  pain  and  tenderness  in  the  epigas- 
trium. He  vomited  only  when  he  forced  himself,  and  then  brought 
up  food  taken  one  or  two  days  previously.  No  hsematemesis  or 
melaena.  For  past  7  months  no  food  but  milk.  Has  lost  100  lbs. 
in  weight.  Says  he  cannot  retain  more  than  6  oz.  in  his  stomach 
at  one  time.  Physical  examination  was  negative  except  for  tender- 
ness and  rigidity  in  the  epigastric  region.  Examination  of  his  stom- 
ach contents  showed:  total  acidity  10;  no  free  hydrochloric  acid; 
no  lactic  acid;  no  Oppler-Boas  bacilli.  Blood-count :  R.  B.  C, 
3,410,000;  W.  B.  C,  8,000;  Hb.  62  per  cent.;  colour  index  0.8. 

Operation  June  3,  1906.  The  stomach  was  found  much  con- 
tracted, its  walls  dense  and  fibrous,  and  resembling  in  appearance 
and  shape  the  small  bowel.  Posterior  gastro-jejunostomy  was  done, 
the  gastric  wall  being  an  inch  in  thickness.  Recovery  was  unevent- 
ful, and  the  patient  is  now  in  good  health,  nearly  2^  years  after  the 
operation. 

REFERENCES. 

Brissaud:    Semaine  Med.,  1900,  xx,  415. 

Eiselsberg:    Surg.,  Gyn.  and  Obst.,  1908,  ii,  254. 

Gayet  and  Patel:   Arch.  Gen.  de  Med.,  1904,  cxciii,  769. 

Jaboulay:   Lyon  Med.,  1905,  civ,  396. 

Jonnesco  and  Grossman:    Revue  de  Chir.,  1908,  xxxvii,  18. 

Kurt  von  Sury:   Arch.  f.  Verdauungskrankh.,  1907,  xiii,  i. 

Leersum:   Deut.  med.  Woch.,  1900,  xxvi,  L.  B.,  S.  67. 

Morone:  Riforma  Medica,   1908,  Nos.  21,  22,  23;   in  Journal  de  Chir. 

Paris,  1908,  i,  491. 
MouDin:  Lancet,  Jan.  19,  1907. 
Sheldon:  Annals  of  Surgery,  1906,  ii,  666. 


CHAPTER  X. 

MISCELLANEOUS  AFFECTIONS    OF   THE  STOMACH    AND 

DUODENUM. 

Tuberculosis  of  the  Stomach  is  rare.  There  are  somewhat 
more  than  one  hundred  cases  recorded.  According  to  Cursch- 
mann,  in  900  autopsies  on  tuberculous  subjects  Diirk  found  the 
stomach  involved  in  only  4  cases;  and  in  2000  autopsies  Simmonds 
found  only  8  tuberculous  ulcers  of  the  stomach;  while  Glaubitt,  ac- 
cording to  Barchasch,  noted  47  tuberculous  ulcers  in  autopsies  on 
2237  tuberculous  patients.  Adler  compares  these  figures  with  11 
cases  of  tuberculous  gastric  ulcer  found  in  839  autopsies  on  tuber- 
culous children;  which  makes  it  appear  rather  less  unusual  in  chil- 
dren than  in  adults.  Ricard  and  Chcvrier  have  recently  written 
an  elabourate  paper  on  the  subject  of  Tuberculosis  and  Tubercu- 
lous Stenosis  of  the  Pylorus;  and  much  of  what  follows  is  ab- 
stracted from  their  valuable  article. 

Louis,  in  1825,  first  recognized  tuberculosis  of  the  stomach; 
but  Hattute  (1874)  was  the  earliest  to  note  pyloric  stenosis  from 
tuberculosis;  and  it  was  not  until  1894  that  the  subject  was  brought 
prominently  before  the  profession  by  Durante. 

It  is  important,  in  the  hrst  ])lacc,  to  distinguish  between  gastric 
ulcers  occurring  in  tuberculous  patients,  and  those  ulcers  due  to 
the  local  action  of  the  tubercle  bacillus.  The  former  may  be  of 
the  ordinary  type  ("round,"  "acute,"  "clironic,"  etc.)  or  in  some 
instances  may  be  due  to  the  toxaemia  of  tuberculosis  localized  in 
other  parts,  the  ulcers  thus  resembling  in  origin  those  erosions  on 
which  Dieulafoy  and  more  recently  his  ])U])il  Gandy  have  laid  such 
stress,  as  caused  by  the  toxa-mia  of  \arious  infectious  diseases. 
If  the  toxa-mia  of  t  u!)cr(  ulosis  gi\e  rise  to  mucous  erosions  in  the 
stomach,  these  erosions  may  later  become  infected  with  the  tubercle 
bacillus,   either  ingested   with   the   food,   or  swallowed   with    the 


Gastric  Tuberculosis.  239 

sputum.  Or  a  true  tuberculous  ulcer  may  possibly  arise  de  novo, 
without  the  previous  existence  of  an  erosion  or  an  open  ulcer.  Sec- 
ondary infection  of  an  already  existing  gastric  lesion  is  probably 
much  the  more  frequent  origin.  The  portal  of  entry  is  usually 
through  the  gastric  mucous  membrane,  from  the  cavity  of  the 
stomach;  though  infection  by  the  blood  and  lymph  streams  is  also 
recognized  as  possible.  The  rarity  of  the  affection  is  no  doubt 
due  to  the  short  time  that  the  ingesta  normally  remain  in  the  stom- 
ach, as  well  as  to  the  antiseptic  action  of  the  gastric  juice.  Cer- 
tainly intestinal  tuberculosis  is  much  more  frequent  than  is  gastric 
(Barchasch  says  the  intestines  are  involved  in  from  47  to  63  per 
cent,  of  phthisical  patients  who  come  to  autopsy) ;  and  gastric 
tuberculosis  when  it  does  occur  is  in  the  immense  majority  of  cases 
secondary  to  some  tuberculous  lesion  in  other  parts  of  the  body, 
particularly  the  lungs  or  bronchial  lymph  nodes.  According  to 
Van  Valzah  and  Nisbet,  "sometimes  the  only  detectable  local  lesion 
is  tubercle  of  the  choroid  or  a  laryngeal  or  nasal  ulcer."  They 
also  remind  the  reader  that  the  tubercle  bacillus  may  be 
found  in  the  urine  when  it  is  absent  from  the  sputum.  Its  differ- 
entiation from  the  smegma  bacillus  is  important,  when  search  is 
made  for  it  in  the  urine.  i\ccording  to  Alessandri  there  were  in 
1905  only  four  authentic  cases  of  primary  gastric  tuberculosis  on 
record.  Barchasch  (1907)  admits  six  cases  as  examples  of  un- 
doubted primary  tuberculosis  of  the  stomach. 

The  tubercle  bacillus  may  pass  through  the  gastric  mucosa, 
leaving  it  intact,  and  lodge  and  proliferate  in  the  neighbouring  lymph 
nodes.  This  is  very  unusual.  When  the  lymph  nodes  have  been 
long  involved,  wdiether  primarily  or  secondarily  diseased,  they 
become  caseous  and  sometimes  calcareous.  Those  along  the  lesser 
curvature  may  soften  and  rupture  into  the  cavity  of  the  stomach; 
but  at  the  pylorus  the  thickness  of  the  wall  is  so  great  as  to  prevent 
this  termination.  Peripyloric  tuberculous  lymphatic  involvement 
is  sometimes  a  cause  of  pyloric  stenosis  without  lesions  of  the  gas- 
tric mucous  membrane. 

Poncet  and  Leriche  distinguish  three  main  forms  of  surgical 
tuberculosis  of  the  stomach:   an  ulcerated  form,  which  is  rendered 


240     Miscellaneous  Affections  of  Stomach  and  Duodenum. 

surgical  only  by  its  complications;  an  hypertrophic  form,  the  gastric 
tuberculoma,  simulating  carcinoma;  and  finally  an  inflammatory 
form,  which  difl'ers  from  other  forms  of  gastritis  only  in  its 
^etiology. 

Gastric  tuberculosis  is  almost  always  ulcerated.  The  disease 
affects  by  preference  the  submucous  and  subserous  tissues,  the 
muscular  tunic  escaping  as  a  rule.  But  in  the  pyloric  region,  where 
the  disease  usually  assumes  the  hyperplastic  form,  the  muscular 
coat  is  prone  to  invasion.  In  the  body  of  the  stomach  tuberculo- 
sis is  usually  diffuse.  The  ulcers  are  ragged,  undermined,  leaving 
free  overhanging  edges  of  mucosa;  and  when  of  long  duration  are 
seated  on  characteristic  raised  and  thickened  bases,  called  by  the 
French  "reinparts.'"  The  ulcer  often  assumes  the  transverse 
character,  parallel  with  the  blood  vessels,  as  are  the  similar  ulcers 
of  the  intestine.  Perigastritis  usually  occurs  in  time  to  protect 
against  perforation  into  the  abdominal  cavity;  and  hemorrhage 
also  is  rare.  In  some  cases  the  duodenum  has  been  opened  by 
ulceration,  forming  a  gastro-duodenal  fistula.  This  may  tempo- 
rarily relieve  the  symptoms  of  pyloric  stenosis.  The  colon  has  also 
been  penetrated  by  the  ulceration  of  a  tuberculous  gastric  ulcer. 
Perforation  of  the  oesophagus  by  a  tuberculous  ulcer  was  the  cause 
of  death  in  a  patient  of  Giorgi,  who  was  found  at  autopsy  also  to 
have  had  tuberculous  ulcers  of  the  stomach. 

Among  the  107  cases  of  gastric  tuberculosis  studied  by  Ricard 
and  Chevrier  there  were  only  three  in  which  no  other  portion  of  the 
digestive  tract  was  involved  in  tuberculous  disease.  The  small 
intestine,  the  mesenteric  lymph-nodes,  and  the  caecum  are  oftcncst 
affected. 

The  symptoms  are  those  of  gastric  ulcer.  Pyloric  stenosis 
from  tuberculous  hyperplasia  is  one  of  the  least  usual  forms  of  the 
disease.  When  present,  it  is  not  difficult  to  detect  the  stenosis,  by 
the  usual  symptoms  and  physical  signs;  but  it  is  only  by  a  search- 
ing examination  for  tuberculous  lesions  elsewhere  in  the  body  that 
the  a;tiological  diagnosis  of  the  gastric  lesion  can  be  made.  The 
tuberculin  test  may  aid  in  determining  the  question.  At  operation 
it  is  frequently  very  diflicult  to  distinguish  these  cases  from  those 


Gastric  Tuberculosis.  241 

of  pyloric  carcinoma.     Inflammatory  hyperplasia,  plastic  linitis, 
and  even  syphilis  have  to  be  considered. 

The  prognosis,  so  long  as  there  is  no  pyloric  stenosis,  depends 
rather  upon  the  other  tuberculous  lesions  in  the  body  than  upon 
those  in  the  stomach.  If  pyloric  stenosis  is  present,  the  prognosis 
is  absolutely  bad,  v^ithout  operation. 

The  operative  treatment  of  gastric  tuberculosis  has  so  far  ac- 
complished little  beyond  relieving  the  most  distressing  symptoms 
and  moderately  prolonging  life.  We  have  found  references  to  over 
twenty  operations  for  this  condition.  In  18  instances  sufhcient  de- 
tails are  available  for  analysis.  Of  these  18  patients,  5  died  as  a 
consequence  of  the  operation,  while  13  survived  for  varying 
periods.  Of  these  thirteen  surviving  patients,  8  have  been  traced  to 
their  death,  which  occurred  at  an  average  period  of  eight  months  after 
the  operation.  A  ninth  patient  survived  for  three  and  one-half  years, 
and  then  died  from  an  abscess  of  the  liver,  the  exact  cause  of  which 
could  not  be  determined  at  autopsy.  Four  patients  who  survived 
operation  for  some  time  were  well  when  reported,  but  the  period 
elapsed  was  too  short  to  be  conclusive. 

Operation  is  not  advisable  except  to  relieve  pyloric  obstruction; 
but  if  it  can  be  determined  that  other  tuberculous  lesions  in  the  body 
are  not  such  as  to  render  the  expectation  of  life  unreasonably  limited, 
it  may  be  proper  in  selected  cases  to  undertake  exploratory  laparo- 
tomy with  a  view  of  prolonging  life  by  improving  nutrition  through 
the  means  of  some  palliative  operation.  Ricard  and  Chevrier  se- 
verely condemn  all  attempts  at  excision  as  futile  and  extremely  liable 
to  disseminate  the  tuberculous  process.  If,  however,  the  disease  is 
limited  to  the  pylorus,  and  especially  if  the  tuberculosis  is  primary 
in  the  stomach,  partial  gastrectomy  should  be  preferred.  It  has 
been  successfully  employed  by  Alessandri  and  by  Docq,  In  other 
cases  the  nature  of  the  operation  will  depend  upon  the  local  conditions 
and  upon  the  extent  of  constitutional  involvement.  Gastrolysis  may 
be  sufficient  when  the  pyloric  obstruction  is  caused  by  perigastric 
tuberculous  peritonitis.  In  most  cases  gastro-jejunostomy  is  the 
operation  of  choice.  In  some  patients  pyloroplasty  may  give  satis- 
factory results. 
16 


242     Miscellaneous  Affections  of  Stomach  and  Duodenum. 

Operations  have  been  performed  on  patients  with  gastric  tuber- 
culosis by: 

1.  Ricard  (Revue  de  Chir.,  1905,  xxxii,  97).     In  1889,  anterior  gas- 

tro-jejunostomy,  followed  by  entero-anastomosis  four  days  later 
for  vicious  circle.  Recovered.  Died  18  months  later  of  tuber- 
culous peritonitis. 

2.  Durante  (Cited  by  Ricard  and  Chevrier:  Revue  de  Chir.,  1905, 

xxxii,  81).  In  1893,  pyloroplasty  (by  Durante's  method).  Re- 
covered.    Ultimate  result  not  stated. 

3.  Durante  (Ibid.).     In  1893,  gastro-jejunostomy.     Recovered;  but 

another  operation  was  done  one  month  later  for  diffuse  miUary 
tuberculosis  of  peritoneum.     Ultimate  result  not  stated. 

4.  Ferrari  (Cited  by  Alessandri:  Bull.  d.  r.  Accad.  med.  di  Roma, 

1905,  xxxi,  267).  In  1893,  posterior  gastro-jejunostomy.  Re- 
covered; but  died  four  months  later  of  phthisis. 

5.  Durante  (Cited  by  Alessandri:   Bull.  d.  r.  Accad.  med.  di  Roma, 

1905,  xxxi,  267).     In  1895,  gastro-jejunostomy.     Died. 

6.  Mayo  Robson  (Lancet,  1902,  ii,  851;  Diseases  of  the  Stomach, 

N.  Y.,  1904,  p.  455).  In  1895,  pyloroplasty.  Died  in  two 
weeks. 

7.  Margarucci  (II  Polichnico,  1898,  v,  Sez.  Chir.,  250).     In  1898, 

anterior  gastro-jejunostomy,  and  two  enteroplasties  for  tuber- 
culous strictures  of  ileum.     Died  in  three  days. 

8.  Herczel  (Cited  by  Alessandri:  Bull.  d.  r.  Accad.  med.  di  Roma, 

1905, xxxi,  267).  In  1 899  posterior  gastro-jejunostomy.  Symp- 
toms unrelieved.  Three  months  later,  anterior  gastro-jejun- 
ostomy. Improved.  Still  later  pylorus  was  excised.  Death 
followed  in  six  months  from  pulmonary  phthisis.  A  biliary 
fistula  had  persisted  since  last  operation. 

9.  Ricard  (Revue  de  Chir.,  1905,  xxxii,  97).     In  1901,  gastrolysis, 

with  suture  of  subacute  perforation  of  stomach,  from  tuber- 
culous ulcer.     Recovered,  but  died  some  months  later  from 
perforation  and  internal  hemorrhage. 
ID.  Ricard    (Ibid.).     In  1901   ])()slerior  gaslro  jcjunoslomy.     Recov- 
ered; but  died  in  less  than  one  year  of  tuberculous  ]KTitonitis. 

11.  Vcrhoogen  (Coddart-Danhieux:  La  Policlinique,  Bruxelles,  1901, 

X,  185).     In    Kjoi,  gastro-jejunostomy.     Died  same  evening. 

12.  Vcrhoogen   (Godart-Danhieux,  Ibid.,  loc.  cit.,  p.  481,  cited  by 

Ricard  and  Chevrier:  Revue  de  Chir.,  1905,  xxxii,  97).  In 
1901,  gastro-jejunost()m\' ;ind  ])l;istic  ojjcration  on  colon.  Died 
in  four  days. 


Gastric  Tuberculosis.  243 

13.  Chevassau  (Cited  by  Ricard  and  Chevrier:  Revue  de  Chir.,  1905, 

xxxii,  97).  In  1902,  posterior  gastro-jejunostomy.  Recovered. 
Died  three  and  one-half  years  later,  from  abscess  of  liver  of 
undiscoverable  origin. 

14.  Ricard  and  Chevrier  (Revue  de  Chir.,  1905,  xxxii,  97).     In  1903, 

posterior  gastro-jejunostomy.  Relieved,  but  died  in  a  few 
months. 

15.  Petersen  (Curschmann:  Beitr.  z.  Khn.  d.  Tuberk.,  1904,  ii,  127). 

In  1904,  posterior  gastro-jejunostomy.  Relieved.  Died  in 
less  than  three  months  of  phthisis. 

16.  Riige  (Beitr.  z.  Klinik    d.  Tuberk.,   1905,  iii,   191).     In  1905, 

pyloroplasty.  Relieved,  but  in  two  months  posterior  gastro- 
jejunostomy done  for  recurrence  of  symptoms.  Died  four- 
teen months  after  first  operation. 

17.  Alessandri  (Bull.  d.  r.  Accad.  med.  di  Roma,  1905,  xxxi,  267). 

In  1905  partial  gastrectomy  (Kocher's  method),  for  tubercu- 
lous stenosis  of  pylorus.  Recovered,  and  in  good  health  forty- 
five  days  later. 

18.  Mattoli    (Cited  by  Alessandri,  loc.  cit.).      Recurrent  case;    no 

details. 

19.  Mattoli    (Cited   by  Alessandri,   loc.    cit.).     Recurrent   case;   no 

details. 

20.  Durante    (Cited   by  Alessandri,  loc.  cit.).     Gastro-jejunostomy; 

very  recent  case. 

21.  Docq  (Presse  Med.  Beige,  1907,  lix,  797).     Partial  gastrectomy, 

with  posterior  trans-mesocolic  gastro-jejunostomy.  Recov- 
ered.    Recent  case. 

22.  Poncet  and  Leriche  (Revue  de  Chir.,  1908,  i,  855)  mention  having 

operated  on  four  patients  with  gastric  tuberculosis.  No  de- 
tails are  recorded. 

23.  Tichoff  (Cited  by  Bereznegovsky:    Chirourgia,  1908,  xxiii,  632; 

in  Journal  de    Chir.,   1908,  I,  489).     In   1908,  pylorectomy 
(Billroth  I)  for  tuberculoma.     Recovered. 

24.  25.  Operations  by  Nordmann  and  Lipscher,  mentioned  by  Ber- 

eznegovsky (Jour,  de  Chir.,  1908,  i,  489). 

REFERENCES. 

Adler:  Amer.  Jour.  Med.  Sc,  1907,  i,  138. 
Alessandri:  Bull.  d.  r.  Accad.  med.  di  Roma,  1905,  xxxi,  267. 
Barchasch:   Beitr.  z.  klin.  d.  Tuberk.,  1907,  viii,  225. 
Curschmann:   Beitr.  z.  klin.  d.  Tuberk.,  1904,  ii,  127. 
Docq:  Presse  Med.  Beige,  1907,  lix,  797. 


244    Miscellaneous  Affections  of  Stomach  and  Duodenum. 

Gandy:   These  de  Paris,  1899. 
Giorgi:  Policlinico,  1903,  Sez.  Med.,  225. 
Leven:  Bull,  et  Mem.  Soc.  Anat.  Paris,  1901,  Ixxvi,  114. 
Poncet  and  Leriche:   Revue  de  Chir.,  1908,  i,  855. 
Ricard  and  Chevrier:   Revue  de  Chir.,  1905,  xxxi,  557;   736. 
Van  Valzah   and  Nisbet:    Diseases    of   tlie   Stomach,    London,  1900,    p. 
S4S. 


Gastric  Syphilis.  245 

Syphilis  of  the  Stomach.  It  has  been  said  that  the  stomach 
is  affected  in  about  one  per  cent,  of  syphiHtic  patients.  Among  243 
autopsies  which  showed  unmistakable  lesions  of  syphilis,  Chiari  found 
syphilitic  lesions  of  the  stomach  in  three  cases.  In  1898  Flexner  was 
able  to  collect  only  fifteen  authentic  instances  of  gastric  syphilis,  in- 
cluding one  of  his  own.  During  the  last  decade  the  attention  of  sur- 
geons as  well  as  physicians  has  been  more  particularly  directed  to  the 
stomach,  and  a  number  of  other  observations  have  been  published, 
there  being  now  on  record  probably  almost  fifty  cases  of  gastric  syph- 
ilis. Since  Flexner's  article  appeared  cases  have  been  recorded  by 
Baylac  and  Chamayou,  Bird,  Einhorn,  Hayem,  Hoover,  JuUien, 
Kirsch,  Lafieur,  Lenzmann,  Morgan,  Schmaler,  Torres  Barbera, 
Tuffier,  and  others. 

As  in  the  case  of  tuberculosis  it  is  important  to  distinguish  ordinary 
ulcers  of  the  stomach  occurring  in  syphilitic  persons,  from  gastric 
lesions  primarily  due  to  the  syphilitic  virus.  In  determining  the  true 
nature  of  the  lesion,  the  microscopical  appearances  are  a  surer  test 
than  is  the  result  of  specific  treatment.  There  is  very  good  reason  to 
believe  that  anti-syphilitic  treatment  will  favourably  influence  the 
course  of  non-specific  gastric  lesions  in  syphilitic  subjects,  by  improv- 
ing the  general  health ;  and  therefore  it  should  not  be  assumed  that  the 
gastric  lesions  are  specific  merely  because  a  course  of  mercurials  or 
iodides  prescribed  for  a  syphilitic  patient  is  followed  by  subsidence  of 
the  gastric  symptoms.  Yet  it  must  also  be  remembered  that  in  the 
interpretation  of  histological  appearances  even  professed  pathologists 
are  not  always  in  accord,  and  that  this  is  particularly  the  case  with 
syphilitic  as  well  as  with  cancerous  lesions. 

Syphilis  affects  the  stomach  either  as  a  diffuse  infiltration,  invading 
especially  the  submucous  tissues,  or  as  a  distinct  tumor — a  syphiloma 
or  gumma.  In  either  case  the  lesions  are  prone  to  ulcerate,  as  a  result 
of  the  endarteritis  and  consequent  interference  with  the  nutrition  of 
the  overlying  mucosa.  In  Flexner's  patient,  whose  stomach  was  the 
seat  of  an  ulcerated  submucous  gummatous  infiltration,  death  occurred 
from  perforative  peritonitis.  In  other  cases,  stricture  may  result. 
More  common  as  a  cause  of  obstruction  is  the  localized  syphiloma. 


246     Miscellaneous  Affections  of  Stomach  and  Duodenum. 

Bird  claims  to  have  observed  12  cases  of  gastric  syphiloma,  the  pylorus 
being  the  seat  of  the  tumor  in  1 1  of  the  patients. 

Svphilitic  gastritis,  in  which  there  may  be  no  specific  lesions  of  the 
stomach,  is  a  fairly  frequent  accompaniment  of  the  disease.  It  is 
often  encountered  in  patients  with  hereditary  syphilis.  It  is  some- 
times caused  by  anti-syphilitic  treatment. 

The  diagnosis  of  gastric  syphilis  rests  on  three  points :  first,  the  his- 
tory of  syphilis  in  the  individual  patient ;  second,  the  resistance  of  the 
gastric  symptoms  to  all  ordinary  remedies ;  and  third,  the  rapid  ame- 
lioration under  specific  treatment.  But  even  though  all  three  of  these 
postulates  be  fulfilled,  the  gastric  lesions  may  not  be  due  to  a  local 
manifestation  of  the  syphilitic  virus ;  and  even  though  one  or  more  of 
these  factors  be  wanting,  the  lesions  of  the  stomach  may  yet  be  syph- 
ilitic. Fen  wick  writes:  "These  cases  chiefly  differ  from  the  simple 
variety  of  the  disease"  (gastric  ulcer)  "in  three  particulars,  the  first 
of  which  is  the  extreme  severity  of  the  pain  and  vomiting,  the  second 
the  infrequency  of  hemorrhage,  and  the  third  their  obstinacy  to  ordi- 
nary treatment  and  their  great  tendency  to  relapse." 

Operative  treatment  is  demanded  only  when  one  of  the  gastric  ori- 
fices is  obstructed  by  a  syphiloma  which  is  unaffected  by  specific  treat- 
ment. Morgan  reported  the  case  of  a  patient  who  had  suffered  for 
four  years  from  anorexia,  flatulence,  thirst,  and  dilated  stomach  with 
pyloric  obstruction;  these  symptoms  were  attended  by  loss  of  weight, 
progressive  emaciation,  and  finally  the  devclopcmcnt  of  a  palpable 
mass  in  the  pyloric  region.  As  syphilis  was  denied,  a  diagnosis  of 
carcinoma  was  made;  but  the  patient  finally  acknowledged  having 
had  a  chancre,  followed  by  secondary  lesions,  four  years  previously. 
Iodide  of  potash  was  administered,  the  symptoms  were  ])romptly 
relieved,  and  health  was  restored.  Tuftier  in  1899  did  gastro-jcjun- 
ostomy  in  a  syphilitic  negro,  in  whom  the  pylorus  was  obstructed  by 
a  large,  firm,  ehislic  tumor  which  fh'sap])earc(l  four  months  after  the 
operation.  It  is  only  rarely  that  excision  is  to  be  un(k'rtaken.  If 
any  operation  is  requisite  to  aid  the  mercurials  and  iodides,  some 
palliative  procedure  is  to  be  preferred:  gastro-jejunostomy  for  pyloric 
stenosis,  and  gastro.stomy  for  obstruction  of  the  canh'ac  orifice.  Of 
course  if  the  tumor  is  possibly,  l)Ul  not  certainfv  mah'gnant,  and  is 


Gastric  Syphilis.  247 

operable,  excision  should  be  done.  Bird  and  others  lay  much  stress 
on  the  hepatic  and  peritoneal  involvement  as  characteristic  of  syph- 
ilis; Bird  considers  of  importance  the  presence  of  "bluish  striae  fol- 
lowing the  course  of  the  lymphatics,  or  of  splotches  of  opaque  bluish 
white  on  the  serosa,  or  of  starred  cicatrices  with  strongly  fibrous  or 
even  calcareous  centers."  Tuffier  thinks  it  probable  that  those  py- 
loric tumors  which  disappear  rapidly — in  a  few  weeks — after  a  pal- 
liative operation,  are  really  cancerous,  and  that  their  disappearance 
is  due  merely  to  their  ascent  beneath  the  ribs  owing  to  the  evacua- 
tion of  the  stomach  through  the  gastro-enterostomy.  Schwartz  said 
that  this  seemed  to  be  the  explanation  in  a  patient  of  his,  in  whom 
the  tumor,  which  disappeared  in  three  or  four  weeks,  was  really 
cancerous,  since,  although  the  gastro-enterostomy  was  working 
well,  secondary  nodules  had  subsequently  developed  in  the  great 
omentum. 

Unless  there  is  very  good  reason  to  suspect  a  syphilitic  origin  for 
the  gastric  symptoms,  the  surgeon  will  best  consult  the  interests  of 
his  patient  by  not  delaying  too  long  an  operation  which  is  clearly 
indicated,  for  the  sake  of  trying  the  effect  of  anti-syphilitic  remedies. 
He  should  bear  in  mind,  moreover,  that  symptoms  of  gastric  distress 
in  a  syphilitic  patient  are  frequently  caused  by  the  ingestion  of  anti- 
syphilitic  remedies;  and  should  such  a  cause  for  the  symptoms  be 
probable,  these  remedies  should  be  discontinued  temporarily,  or  be 
administered  hypodermatically  or  by  inunction.  On  the  other  hand, 
should  the  syphihtic  origin  of  the  gastric  lesions  become  manifest  by 
operation  or  otherwise,  no  time  should  be  lost  in  getting  the  patient 
under  the  influence  of  mercury  and  the  iodides:  such  treatment  will 
be  an  important  adjuvant  to  any  operation  that  shall  have  been  per- 
formed. 

Operations  for  syphilitic  lesions  of  the  stomach  have  been  recorded 
by: 

1.  Baylac  and  Chamayou  (Arch.  Med.  de  Toulouse,  1901,  vii,  145). 

Exploratory   laparotomy.     Wound    closed.     Recovery   under 
anti-syphilitic  treatment. 

2.  Bird  (Surg.  Gyn.  and  Obst.,  1907,  iv,  635).     Partial  gastrectomy 

for  supposed  cancer  of  the  pylorus.     Eventual  recovery. 


248     Miscellaneous  Affections  of  Stomach  and  Duodenum. 

3.  Bird  (Ibid.,  loc.  cit.).     Exploratory  laparotomy.     Wound  closed. 

Recovery  under  anti-syphilitic  treatment. 

4.  Bird  (Ibid.,  loc.  cit.).     Exploratory  gastrotomy.     Recovery  under 

anti-syphilitic  treatment. 

5.  Hayem  (Presse  Med.,  1905,  i,  105;  Allg.  Wien.  med.  Zeit.,  1905, 

1,  383,  393.   Case  3).     Gastro-jejunostomy  as  a  last  resort  for 
pyloric  obstruction.     Death. 

6.  Hayem  (Ibid.,  loc.  cit..  Case  4).     Partial  gastrectomy  for  tumor 

thought  to  be  cancer.     Recovery. 

7.  Lafleur  (Montreal  Med.  Jour.,   1903,  xxxii,  488).     Exploratory 

gastrotomy  by  Armstrong;  a  piece  of  gastric  wall  removed  for 
examination.     Recovery. 

8.  Tuffier  (Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  1899,  xxv,  837). 

Gastrectomy  for  pyloric  obstruction.     Recovery. 

REFERENCES. 

Bird:   Surg.  Gyn.  and  Obstetr.,  1907,  iv,  635. 

Chiari:      Internat.    Beitr.    z.    Wissenschaft.    Medicin    (Festchr.    Rudolf 

Virchow),  1891,  ii,  297. 
Fenwick:   Cancer  and   Other  Tumoius  of  the  Stomach,  London,   1902, 

p.  316. 
Flexner:  Amer.  Jour.  Med.  Sc,  1898,  ii,  424. 
Morgan:  Amer.  Med.,  1906,  xii,  123. 
Schwartz:   Bull,  et  Mem.  Soc.  Chir.  Paris,  1899,  xxv,  838. 
Tuffier:  Bull,  et  Mem.  Soc.  Chir.  Paris,  1899,  xxv,  837. 


Phlegmonous  Gastritis.  249 

Phlegmonous  Gastritis.  Phlegmonous  gastritis  is  a  rare  form 
of  inflammation  of  the  stomach,  which  has  been  recognized,  according 
to  Schnarrwyler,  since  1656,  when  a  case  was  first  observed  by  P- 
Borel.  It  has  been  described  under  a  multitude  of  names,  which 
are  given  at  length  by  Leith,  and  of  which  the  most  frequently  em- 
ployed are  "submucous  gastritis"  and  "suppurative  linitis." 

The  disease  is  defined  by  Schnarrvn^der  as  a  "diffuse  purulent 
inflammation  of  the  stomach,  which  has  its  chief  seat  in  the  sub- 
mucosa,  but  which  may  later  produce  a  lymphy  and  finally  purulent 
infiltration  of  the  intermuscular  connective  tissue,  and  thus  even- 
tually reach  the  serosa;  while  on  the  other  hand  the  overlying 
mucosa  becomes  infiltrated  with  pus  cells  and  swollen." 

Robson  and  Moynihan,  in  their  work  on  Diseases  of  the  Stomach, 
have  gone  into  the  pathology  and  symptoms  in  considerable  detail, 
and  little  can  be  added  to  what  they  then  wrote.  They  tabulated 
85  cases  of  the  disease,  collected  from  various  sources,  including 
three  original.  Schnarrwyler,  writing  a  couple  of  years  later,  ac- 
cepted as  authentic  only  80  cases  found  in  the  literature,  and  added 
three  which  had  been  observed  by  himself.  Robertson  in  1907 
reported  two  new  cases  (found  at  autopsy),  and  collected  six  cases 
from  the  literature  since  the  publication  of  Schnarrwyler's  mono- 
graph. According  to  the  definition  given  above,  only  diffuse  sub- 
mucous inflammations  should  be  included ;  but  as  there  is  no  doubt 
that  well  localized  phlegmons  of  the  gastric  wall  are  occasionally 
encountered,  it  seems  scarcely  worth  while  to  make  a  separate  clas- 
sification for  "phlegmon  ventriculi,"  and  we  therefore  agree  with 
Robson  and  Moynihan,  who  describe  phlegmonous  gastritis  as  exist- 
ing in  two  forms,  the  circumscribed  and  the  diffuse. 

Although  there  seems  good  reason  to  believe  that  the  disease 
occasionally  arises  without  any  macroscopical  lesion  of  the  gastric 
mucosa,  it  is  more  frequently  encountered  as  a  complication  of  gas- 
tric ulcer,  or  a  sequel  to  some  operation  on  a  stomach  which  is 
already  the  seat  of  catarrhal  gastritis.  The  streptococci  are  the 
micro-organisms  most  often  found;  but  staphylococci,  colon  bacilli, 
and  even  gas  bacilli,  have  been  recovered  from  the  stomach  in  some 
instances. 


250     Miscellaneous  Affections  of  Stomach  and  Duodenum. 

Operations  have  proved  the  exciting  cause  in  cases  recorded  by 
Schnarrwyler,  Eiselsberg,  Page,  and  others.  In  Schnarrwyler's 
patient  an  anterior  gastro-jejunostomy  had  been  done  by  Hildebrand 
for  an  inoperable  mass  obstructing  the  pylorus.  Death  followed 
in  five  davs;  and  the  autopsy  showed  that  it  was  caused  by  a  diffuse 
scro-purulent  peritonitis  arising  in  a  purulent  infiltration  of  the 
stomach  walls,  which  had  not  been  present  at  the  time  the  operation 
was  done.  In  Eiselsberg's  patient  death  from  phlegmonous  gas- 
tritis follo'wed  six  days  after  he  did  "gastro-enterostomia  retrocolica 
anterior";  and  in  a  patient  operated  on  by  Page,  fatal  phlegmonous 
gastritis  followed  the  performance  of  gastrostomy  for  stricture  of 
the  oesophagus. 

The  clinical  picture  presented  by  a  patient  with  diffuse  phleg- 
monous gastritis  is  thus  graphically  summarized  by  Robson  and 
Moynihan:  It  is  that  "of  a  patient  acutely  ill  from  some  febrile 
disease,  with  irregular  elevations  of  temperature,  very  feeble  and 
rapid  pulse,  vomiting,  constant  pain  in  the  abdomen,  referred  gen- 
erally to  the  epigastrium,  and  slight  tenderness  on  deep  palpation. 
It  is  therefore,"  they  proceed,  "not  a  matter  of  surprise  to  learn  that 
a  positive  diagnosis  of  phlegmonous  gastritis  has  never  been  at- 
tempted." 

The  purulent  collections  in  the  submucosa  are  solitary  or  numer- 
ous; the  abscesses  vary  in  size  from  that  of  a  millet  seed  to  that  of  a 
man's  fist;  they  may  perforate  into  either  the  stomach  or  the  abdom- 
inal cavity;  and  in  either  case  are  almost  surely  followed  by  death. 
Whether  the  disease  be  of  the  circumscribed  or  of  the  diffuse  form, 
peritonitis  without  macroscopical  perforation  of  the  gastric  wall  will  be 
the  nearly  inevitable  result;  and  unless  exploratory  operation  were  to 
be  undertaken  on  very  indefinite  symptoms,  ])eritonitis  will  have  de- 
velo})cd  before  a  diagnosis  is  made. 

In  the  circumscribed  form  of  the  disease  it  would  be  possible  to 
evacuate  the  abscess  by  operation;  but  little  could  be  done  for  the 
diffuse  phlegmonous  inflammation.  Possibly  by  isolating  the  stom- 
ach with  sterile  gauze  and  incising  its  walls  down  to  the  mucosa,  or 
even  by  ojK-ning  its  ca\it\-  widely,  a  faxorable  issue  might  l)e  antici- 
pated, if   the  o]K'ration  were  done   Ijcfore  general   ])eritonitis  super- 


Phlegmonous  Gastritis.  251 

vened.  Excision  of  the  diseased  stomach  would  be  impossible  in 
most  cases;  while  formal  gastrostomy  or  gastro-enterostomy,  in  our 
opinion,  could  not  but  add  to  the  gravity  of  the  disease.  It  is  worth 
while  to  note  that  all  recorded  cases  of  the  disease  in  which  the 
diagnosis  is  positive  have  been  found  at  autopsy,  with  the  exception 
of  Mikulicz's  and  Bovee's  patients  who  were  cured  by  operation;  five 
patients  recovered  without  operation,  but  in  these  the  existence  of 
phlegmonous  gastritis  was  only  inferred. 

Operations   on   patients  with   phlegmonous   gastritis  have   been 
performed  by: 

1.  Leith  (Edinburgh  Hospital  Reports,  1896,  iv,  51).     Patient  pre- 

sented symptoms  of  diffuse  purulent  peritonitis.  A  median 
hypogastric  incision  seemed  to  show  that  the  inflammation  was 
more  acute  in  the  right  iliac  fossa.  A  second  incision  was 
therefore  made,  and  the  appendix  removed.  It  did  not  appear 
to  be  gravely  diseased.  The  abdomen  was  irrigated,  the 
wounds  were  closed,  but  the  patient  died  in  seven  hours. 
Autopsy  showed  that  the  peritonitis  arose  from  diffuse  phleg- 
monous gastritis,  and  that  the  inflammation  had  probably 
spread  from  the  stomach  first  to  the  right  iliac  fossa  (as.  is 
frequently  the  case  with  patients  with  perforated  duodenal 
ulcer),  and  had  subsequently  become  generalized. 

2.  Eennander    (Lengemann:    Mitth.    a.   d.    Grenzgeb.   d.   Med.   u. 

Chir.,  1902,  ix,  762).  Patient  with  diffuse  epigastric  peri- 
tonitis. The  stomach  seemed  to  be  the  original  seat  of  the 
disease,  and  it  was  tamponaded.  Death  in  60  hours. 
Phlegmonous  gastritis  found  at  autopsy. 

3.  Mikulicz   (Lengemann:  Mitth.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir. 

1902,  ix,  762).  Patient  with  symptoms  of  perforated  gastric 
ulcer.  Operation  disclosed  sero-purulent  peritonitis  around 
stomach,  from  a  not  well  localized  phlegmon  of  the  gastric 
wall.  No  perforation  found.  Irrigation  and  drainage. 
Recovery. 

4.  Bovee    (Trans.    Southern  Surg,  and  Gyn.  Assoc,  Dec,  1907,  in 

Jour.  Amer.  Med.  Assoc,  1908,  i,  311).  A  case  of  circum- 
scribed suppurative  phlegmonous  gastritis;  recovery  after 
gastrostomy. 


252     Miscellaneous  Affections  of  Stomach  and  Duodenum. 


REFERENCES. 

Bovee:  Amer.  Jour.  Med.  Sc,  1908,  i,  662. 

Leith:   Edinburgh  Hosp.  Reports,  1896,  iv,  51. 

Lennander:    Cited  by  Lengemann:    Mitth.  a.  d.  Grenzgeb.  d.  Med.  u. 

Chir.,  1902,  ix,  762. 
Mikulicz:    Cited    by    Lengemann:    Mitth.  a.  d.    Grenzgeb.    d.    Med.   u. 

Chir.,  1902,  ix,  762. 
Robson   and    Moynihan:    Diseases    of    the    Stomach,    New  York,    1904, 

p.  462. 
Robertson:  Jour.  Amer.  Med.  Assoc,  1907,  ii,  2143. 
Schnamvyler:  Archiv  f.  Verdauungskrankh.,  1906,  xii,  116. 


Volvulus  of  the  Stomach.  253 

Volvulus  of  the  Stomach.  Volvulus  of  the  stomach  ap- 
pears to  have  been  observed  in  only  thirteen  cases.  In  three  cases 
(Langerhans,  Mazzotti,  Saake),  hour-glass  contraction  of  the  stom- 
ach seems  to  have  acted  as  a  predisposing  cause,  though  it  is  doubt- 
ful whether  in  Saake's  patient  a  true  volvulus  existed.  In  other 
cases  no  cause  was  demonstrated,  but  in  some  there  was  noted  a 
marked  lengthening  of  the  gastric  ligaments,  and  in  Berg's  second 
patient  a  tumor  near  the  cardiac  orifice  may  have  excited  undue 
gastric  peristalsis.  The  symptoms  are  usually  pain  in  the  epigas- 
trium, but  without  fever  or  evidence  of  acute  peritonitis.  If  the 
cardia  be  occluded  by  a  twist,  there  will  be  no  vomiting,  and  in- 
troduction of  the  stomach  tube  will  be  difficult  or  impossible;  if  it 
be  not  occluded,  vomiting  will  be  persistent;  and  the  absence  of  bile 
from  the  vomitus  may  be  an  indication  that  the  pylorus  is  occluded. 
The  symptoms  are  those  of  intestinal  obstruction  and  the  physical 
signs  closely  resemble  those  of  acute  dilatation  of  the  stomach;  in- 
deed as  the  usual  effect  of  the  volvulus  is  to  occlude  both  orifices, 
dilatation  of  the  stomach  naturally  follows.  As  already  remarked, 
it  is  very  difficult  or  impossible  to  introduce  a  stomach  tube;  and 
this  fact  alone  shows  that  something  more  than  mere  gastric  dilata- 
tion exists. 

The  rotation  may  take  place  in  any  direction,  though  there  are 
three  more  or  less  typical  directions  in  which  it  usually  occurs. 
These  are  (i)  Around  an  antero-posterior  axis,  in  which  case  the 
stomach  rotates  either  " clockwise "  or  "contra-clockwise"  as  viewed 
from  the  front;  (2)  around  a  transverse  axis  in  the  frontal  plane,  in 
which  case  the  stomach  rotates  as  an  advancing  or  as  a  retreating 
wheel,  viewed  from  the  front  of  the  body;  or  (3)  around  a  longitudi- 
nal axis  in  the  sagittal  plane  (an  axis  more  or  less  at  right  angles  to 
the  greater  curvature),  when  the  stomach  revolves  either  clockwise 
or  contra- clockwise  when  viewed  from  the  head  of  the  patient.  The 
most  frequently  encountered  form  is  volvulus  around  a  transverse 
axis  in  the  direction  of  a  retreating  wheel  (Berg,  2  cases,  Wiesinger, 
Dujon,  Pendl,  Borchardt,  and  Wilke  each  one  case — seven  cases  in 
all).  In  every  instance  but  Borchardt's  patient,  the  transverse 
colon  followed  the  stomach    upward    and    backward,   being   found 


254     Miscellaneous  Affections  of  Stomach  and  Duodenum. 

between  the  stomach  below  and  the  liver  and  diaphragm  above. 
In  Dujon's  patient  the  great  omentum,  except  at  the  pylorus,  and 
the  gastro-splenic  omentum  were  torn  off  from  their  gastric  attach- 
ment by  the  \olvulus.  He  found  that  he  could  not  produce  this 
form  of  A'olvulus  in  the  normal  cadaver,  unless  the  gastro-splenic 
and  great  omenta  were  ruptured.  In  Borchardt's  patient  the 
transverse  colon  maintained  its  normal  position,  but  the  gastro-colic 


titer. 


Gastro-hepatic 
Omentum 


Stomach 

Great 
Omentum 


Transverse 
\  Mesocolon 


Fig.  29. — ^Wiesinger's  Case  of  Volvulus  of  the  Stomach. 


omentum,  \\Iii(li  was  very  broad,  was  stretched  to  its  utmost.  In 
most  cases  the  spleen  has  been  more  or  less  displaced;  it  may  be 
ruptured;  and  cither  from  it  or  the  gastric  vessels,  profuse  hemor- 
rhage into  the  peritoneal  cavity  may  occur. 

Should  the  use  of  the  slomacli  lul;c  ])r()\e  unavailing  in  relieving 
the  di.stcntion,  ])rom])t  ojjcration  is  required.  If  the  stomach  is 
very  tense,  it  should  be  evacuated  by  puncture  or  incision;  when  it 


Volvulus  of  the  Stomach.  255 

becomes  flaccid,  the  puncture  should  be  sutured,  and  the  volvulus 
should  then  be  reduced,  if  possible.  The  surgeon  must  remember 
the  most  frequent  form  of  volvulus  (around  a  transverse  axis),  for 
it  is  often  impossible  to  determine  by  inspection  how  the  viscera 
came  to  occupy  the  positions  in  which  they  are  found.  The  trans- 
verse colon  should  be  sought :  it  usually  will  be  found  close  beneath 
the  liver  or  diaphragm,  and  the  spleen  may  be  beneath  the  ensiform 
process,  in  the  neighbourhood  of  the  gall-bladder,  or  even  in  the 
pelvis.  The  posterior  wall  of  the  stomach  usually  presents,  and  has 
to  be  tapped;  then  as  the  evacuation  proceeds  the  site  of  puncture 
may  become  inaccessible,  and  Berg  was  forced  to  suture  his  first 
puncture  before  the  stomach  was  half  empty,  and  to  make  another 
incision  in  that  part  of  the  gastric  wall  which  then  became  more  ac- 
cessible. If  reduction  cannot  be  accomplished,  the  stomach  should 
be  drained,  to  prevent  subsequent  distention,  and  in  the  hope  that 
spontaneous  reduction  may  subsequently  occur.  If  feasible  this 
drainage  is  to  be  procured  by  means  of  gastro-jejunostomy;  if  this 
cannot  be  done,  a  gastrostomy  will  suffice.  When  reduction  has 
been  successfully  accomplished,  the  stomach  need  not  be  drained, 
and  it  will  not  usually  be  requisite  to  seek  to  prevent  a  recurrence 
of  the  volvulus  by  gastropexy.  In  Berg's  first  patient  no  recurrence 
was  noted,  and  he  was  reported  as  well  more  than  ten  years  after 
the  operation.     (See  Borchardt,  loc.  cit.) 

Operations  for  gastric  volvulus  have  been  done  by: 

1.  Berg,    1895.     Stomach    evacuated     ])y    trocar,    and    untwisted. 

Recovered,  and  well  in  1906. 

2.  Berg,  1896.     Volvulus  untwisted  by  pulling  one  meter  of  small 

bowel  and  the  transverse  colon  from  a  rent  in  gastro-hepatic 
omentum;  then  stomach  itself  followed  them,  and  normal 
condition  w^as  restored.  As  there  was  an  obstructing  tumor 
near  the  cardiac  orifice,  the  first  stage  of  a  gastrostomy  was 
done,  but  as  deglutition  was  not  difficult  during  convales- 
cence the  stomach  was  never  opened. 

3.  Borchardt,  1906.      Gastrotomy;  stomach  evacuated  and  sutured. 

Volvulus  could  not  be  reduced.  Profuse  hemorrhage  from 
rent  in  spleen.  Gauze  packs  to  left  dome  of  diaphragm  to 
check  bleeding.     Died  in  a  few  hours. 


256     Miscellaneous  Affections  of  Stomach  and  Duodenum. 

4.  Delangre,  1907.     Exploratory  laparotomy:  aspiration  and  reduc- 

tion   of    stomach;    gastropexy.     Recovered,    and    well     two 
months  later. 

5.  Dujon,    1903.      Exploratory    laparotomy:    inoperable    condition 

found,  and  wound  closed.     Died  next  day. 

6.  Pendl,  1904.     Stomach  punctured  and  evacuated,  and  volvulus 

untwisted.     Recovered. 

7.  Wiesinger,  1901.     Stomach  punctured  and  evacuated,   and  vol- 

vulus untwisted.     Recovered. 

CASES  OF  VOLVULUS  OF  THE  STOMACH. 

I.  Around  Antero-Posterior  axis. 

(a)  Clockwise — no  cases. 
(&)  Contra-clockwise : 

I.  Streit  (Amer.  Jour.  Med.  Sc,  1906,  i,  967). 

II.  Around  Transverse  Axis  in  Frontal  Plane. 

(a)  As  an  advancing  wheel : 

I.  Delangre  (Revue  de  Chir.,  1907,  xxxvi,  603). 

(b)  As  a  retreating  wheel: 

1.  Berg   (Nord  medicinskt   Arkiv,  Fest-Band,   Stock- 

holm,  1895,  Fall  i;  cited  by  Dujon:  Gaz.  Med. 
de  Paris,  1903,  Ixxiv,  173). 

2.  Berg  (Ibid.,  loc.  cit.). 

3.  Borchardt  (Arbeit,  a.  d.  chir.  Khnik  (Bergmann), 

Berlin,  1906,  xviii,  104). 

4.  Dujon  (Gaz.  Med.  de  Paris,  1903,  Ixxiv,  109). 

5.  Pendl  (Wien.  khn.  Woch.,  1904,  xvii,  476). 

6.  Wiesinger  (Deutsch.  med.  Woch.,  1901,  xxvii,  83). 

7.  Wilke  (Munch,  med.  Woch.,  1907,  liv,  1012). 

III.  Around  Longitudinal  Axis  in  Sagittal  Plane. 

(a)  Clockwise  when  viewed  from  patient's  head. 

I.  Berti  (Gaz.  Med.  Ital.  Venete,  Padova,  1866,  ix, 
139;  cited  by  Dujon:  Gaz.  Med.  de  Paris,  1903, 
Ixxiv,  109). 

(b)  Contra-clockwise  when  viewed  from  patient's  head. 

1.  Langcrhans  (Virchow's  Arch.  f.  path.  Anat.,  cited 

by  Dujon:  Gaz.  Med.  de  Paris,  1903,  Ixxiv,  175). 

2.  Mazzotti  (Rivista  Clinica  di  Bologna,  1899,  iv,  280; 

cited  by  Dujon:  Gaz.  Med.  de  Paris,  1903,  Ixxiv, 

175)- 

3.  Saakc  CVirchow's  Arch.  f.  ]>ath.  Anat.,  1893,  cxxxiv, 

j8i). 


Eventration  of  the  Diaphragm,  257 

Eventration  of  the  Diaphragm. — (Eventratio  Diaphragmatica.) 
This  rare  condition,  which  is  sometimes  confounded  with  diaphrag- 
matic hernia,  is  defined  by  Sailer  and  Rhein  as  "an  abnormally 
high  position  of  the  left  half  of  the  diaphragm,  with  dislocation 
upward  of  the  abdominal  viscera,  particularly  the  stomach,  on 
the  left  side;  hypoplasia  of  the  left  lung,  and  displacement  of  the 
heart  to  the  right."  These  authors,  in  reporting  an  original 
case,  collect  twelve  other  instances  of  this  malformation,  and  it  is 
from  their  valuable  article  that  most  of  what  follow^s  has  been  ab- 
stracted. Arnsperger's  patient  brings  the  total  of  reported  cases 
to  14. 

As  a  rule,  the  symptoms  closely  resemble  those  of  diaphrag- 
matic hernia,  which  is  more  frequent  on  the  left  than  on  the  right 
side ;  but  there  is  in  eventration  of  the  diaphragm  no  history  of  sud- 
den onset  nor  of  trauma;  in  the  immense  majority  of  cases  the  con- 
dition is  congenital,  though  Sailer  and  Rhein  consider  it  possible 
that  an  acquired  form  may  exist.  Although,  as  has  been  stated, 
there  is  usually  no  history  of  a  sudden  onset,  there  may  be  exacer- 
bations of  the  symptoms.  These,  if  manifested  clinically  in  any 
way,  are  apt  to  be  characterized  by  dyspnoea  and  cardiac  palpita- 
tions. The  condition  is  seldom  accurately  diagnosticated  until 
autopsy.  During  life  the  most  prominent  physical  signs  are  dex- 
trocardia and  tympany  in  the  lower  left  chest.  The  differential 
diagnosis  from  pneumothorax  and  diaphragmatic  hernia  is  impor- 
tant ;  indeed,  it  is  only  its  resemblance  to  the  latter  condition  that  ren- 
ders it  of  interest  surgically.  In  pneumothorax,  some  cause  for  the 
anomaly  usually  may  be  discovered,  dating  its  developement ;  and 
the  upper  border  of  the  tympanitic  area  does  not  move  during  res- 
piration, whereas  in  eventration  of  the  diaphragm  this  is  a  constant 
sign.  By  means  of  the  stomach  tube,  distention  of  the  stomach 
with  air  or  liquid  will  demonstrate  its  position,  and  a  skiagraphic 
examination  may  show  that  the  diaphragm  retains  its  normal  level 
in  pneumothorax,  whereas  in  eventration  of  the  diaphragm  it  is. 
markedly  elevated.  Diaphragmatic  hernia  usually  can  be  excluded 
by  the  history.  In  one  case  of  eventration  of  the  diaphragm  studied 
by  Widemann,  a  diagnosis  of  diaphragmatic  hernia  was  made  a  year 
17 


258  Miscellaneous  Affections  of  Stomach  and  Duodenum. 

later  by  G laser.  The  patient,  48  years  of  age,  had  had  four  attacks 
of  pleurisy.  Profuse  gastric  hemorrhage  ushered  in  the  last  at- 
tack, and  the  patient  was  then  taken  to  the  hospital.  All  the  signs 
of  diaphragmatic  hernia  were  present,  but  the  first  skiagraph  made 
showed  that  the  left  side  of  the  diaphragm  was  abnormally  high,  and 
that  the  stomach  was  not  above  it.  (Widemann.)  "Later  a  trans- 
verse line  below  the  clear  area  could  be  seen  moving  with  the  respir- 
atory excursion,  and  a  diagnosis  was  made  of  diaphragmatic  her- 
nia." (Glaser,  quoted  by  Sailer  and  Rhein.)  As  the  hcematemesis 
was  repeated,  the  hernia  was  thought  to  be  incarcerated.  At  the 
operation  (done  byKorte)  no  hernia  was  found.  The  patient  recov- 
ered, but  died  a  year  later  from  carcinoma  of  the  tongue. 

The  treatment  of  patients  with  eventration  of  the  diaphragm 
can  only  be  prophylactic  of  complications. 

REFERENCES. 

Arnsperger:   Deutsch.  Arch.  f.  klin.  Med.,  1908,  xciii,  88. 
Glaser:  Deutsch.  Arch.  f.  klin.  Med.,  1903,  Ixxviii,  370. 
Sailer:  Amer.  Jour.  Med.  Sc,  1905,  i,  688. 
Widemann:   Berlin,  klin.  Woch,,  1901,  xxxviii,  279. 


Diaphragmatic  Hernia.  259 

Diaphragmatic  Hernia. — Diaphragmatic  hernia  has  been  ob- 
served in  probably  more  than  500  cases.  Grosser  in  1899  was 
able  to  find  records  of  433  cases.  This  form  of  hernia  may  be 
classified  as  congenital  and  acquired:  but  here,  as  in  other  hernias, 
a  distinction  must  be  made  between  hernias  which  are  present  at 
birth,  and  those  which,  though  due  to  somiC  congenital  defect  in  the 
diaphragm,  do  not  develope  until  some  time  after  birth,  occasionally 
not  until  late  in  life.  Either  form  of  hernia,  moreover,  may  happen 
to  be  Intraperitoneal,  Subpleural,  Subdiaphragmatic,  or  even 
Intrapericardial  as  in  the  case  recorded  by  Grenier  de  Cardenal. 
Probably  the  least  usual  form  is  the  subdiaphragmatic,  which  is  also 
known  as  "true  diaphragmatic  hernia."  In  this  variety  the  dia- 
phragm becomes  pouched,  and  the  m.uscular  fibres,  even  if  weak 
and  indistinct,  may  nevertheless  be  traced  throughout  the  walls  of 
the  hernial  sac.  Jaffe  collected  13  cases  of  this  variety,  including 
one  observed  by  himself.  If  the  protrusion  occurs  through  a  defect 
in  the  diaphragm,  whether  congenital  or  acquired  (by  stabwound, 
gunshot  wound,  or  traumatic  rupture  of  the  diaphragm),  the  sac 
may  still  be  lined  by  peritoneum;  but  this  is  very  unusual.  The 
pleura  also  is  usually  absent  over  the  hernia,  the  variety  most  fre- 
quently encountered  being  that  in  which  the  herniated  viscera 
(stomach,  colon,  etc.)  lie  free  in  the  pleural  cavity — intrapleural 
hernia. 

The  hernia  is  much  m.ore  often  on  the  left  than  on  the  right  side. 
Among  282  cases  studied  by  Deitz,  in  261  (93.5  per  cent.)  the  hernia 
was  on  the  left.  The  reason  for  the  immunity  of  the  right  side  has 
always  been  said  to  be  the  presence  of  the  liver  beneath  the  dia- 
phragmatic vault,  acting  as  a  buffer,  and  materially  strengthening 
the  right  half  of  the  diaphragm.  There  are  certain  regions  of  the 
diaphragm  in  which  hernia  is  more  apt  to  occur  than  in  others;  these 
are  not,  as  might  be  expected,  the  natural  phrenic  openings,  such  as 
the  oesophageal  and  caval  orifices.  Hernia  through  these  is  rare. 
There  is,  however,  a  triangular  area  found  between  the  costal  and 
sternal  attachments  of  the  diaphragm,  which  is  filled  in  only  with 
areolar  tissue,  and  where  the  abdominal  and  thoracic  cavities  are 
not  separated  by  muscular  fibres.     This  weak  spot  is  sometimes  the 


26o    Miscellaneous  Affections  of  Stomach  and  Duodenum. 

seat  of  a  hernia ;  but  more  often  the  protrusion  occurs  in  the  neigh- 
bourhood of  the  left  leaflet  of  the  central  tendon  of  the  diaphragm. 
In  congenital  hernia  the  defect  is  usually  in  the  posterior  half  of  the 
diaphragm,  which  is  a  later  developement  than  the  ingrowth  from  the 
ventral  surface  of  the  foetus.  In  other  cases  the  hernia  is  situated  in 
the  posterior  part  of  the  diaphragm,  along  the  outer  margin  of  the 
left  crus,  and  beneath  the  internal  arcuate  ligament.  The  most 
frequently  herniated  viscera,  according  to  Deitz,  are  the  stomach, 
colon,  omentum,  small  intestine,  spleen,  liver,  duodenum,  caecum,  and 
kidney — in  the  order  named.  The  bladder,  the  rectum,  and  the 
female  generative  organs  have  never  been  found  in  a  diaphragmatic 
hernia. 

Most  cases  of  diaphragmatic  hernia  are  observed  in  the  foetus, 
or  in  infants  stillborn,  or  dying  very  soon  after  birth.  In  Lacher's 
cases,  the  age  was  recorded  in  204  instances,  and  of  these  no  less  than 
80  (40  per  cent.)  were  in  infants  less  than  one  year  old,  or  in  the 
foetus.  A  child  so  malformed  from  birth  is  very  badly  equipped  for 
the  struggle  for  existence,  and  is  prone  to  succumb  to  intercurrent 
maladies,  especially  pulmonary  affections.  Sudden  death  from 
acute  cardiac  incompetency  is  a  frequent  termination,  especially  in 
adults.  Indeed  it  has  been  said  that  diaphragmatic  hernia  should 
always  be  considered  in  deciding  the  cause  of  a  sudden  death. 

Males  are  supposed  to  be  more  subject  to  this  affection  than  are 
females,  and  Warren  states  that  sailors,  soldiers,  slaters,  and  car- 
penters are  especially  ]jrone. 

Subjective  symptoms  are  often  wanting,  the  malformation  being 
unexpectedly  found  at  autopsy.  In  the  newborn,  cyanosis  and 
dyspnoea  are  prominent;  the  left  thorax  does  not  expand  normally; 
there  is  dextrocardia;  and  death  usually  occurs  within  a  few  hours. 
The  adult  patient  may  have  suffered  from  mild  indigestion,  with 
borborygmi,  and  tym])any  after  eating;  and  this  condition  may  have 
continued  for  years  without  material  discomfort;  at  any  time,  how- 
ever, acute  overdistcntion  of  the  herniated  stomach  may  cause  sudden 
cardiac  failure,  perhaps  death;  or  strangulation  of  the  hernia  may 
arise  from  a  strain  which  forces  a  larger  portion  of  the  abdominal 
contents    through    the    dia])hragmatic    opening.     Great    thirst    is    a. 


Diaphragmatic  Hernia.  261 

symptom  on  which  stress  is  laid  by  many  writers.  The  symptoms 
due  to  stabwounds  or  gunshot  injuries  of  the  diaphragm,  with  pro- 
trusion of  the  stomach  or  colon,  are  usually  overshadowed  by  those 
due  to  the  injuries  to  the  abdominal  viscera  involved. 

The  physical  signs  of  a  diaphragmatic  hernia  are  much  more 
precise  in  theory  than  in  practice.  We  know  certain  so-called 
pathognomonic  signs,  by  means  of  which  diaphragmatic  hernia 
may  be  distinguished  from  pneumothorax  and  other  conditions 
which  it  resembles  more  or  less  closely;  but  when  practical  applica- 
tion is  made  of  the  tests,  it  must  be  acknowledged  that  both  physi- 
cian and  surgeon  frequently  remain  undecided  as  to  the  true  con- 
dition present.  Among  the  276  cases  collected  by  Lacher  in  1880, 
only  seven  were  diagnosticated  during  life;  and  though  our  diag- 
nostic acumen  has  greatly  increased,  in  regard  to  abdominal  dis- 
eases, during  the  last  generation,  still  it  must  be  confessed  that  even 
yet  the  diagnosis  of  diaphragmatic  hernia  is  usually  very  difficult. 
The  physical  signs  and  tests  employed  are  fully  described  in  most 
textbooks  on  the  practice  of  medicine,  and  need  be  outlined  here 
very  briefly:  The  lower  chest  on  the  affected  side  is  tympanitic; 
the  breath  sounds  are  absent  or  very  feeble  and  distant;  vocal 
fremitus  is  lost;  expansion  is  decreased;  and  the  heart  is  dislocated 
away  from  the  affected  side — that  is  to  say,  there  is  usually  dextro- 
cardia. The  same  signs  exist  in  pneumothorax;  but  in  diaphrag- 
matic hernia  the  diaphragm  does  not  descend  on  deep  inspiration, 
and  causes  which  may  produce  pneumothorax  may  nearly  always 
be  absolutely  excluded,  while  a  history  of  sudden  onset  following 
severe  strain  (sometimes  childbirth)  or  a  crushing  injury,  or  occur- 
ring some  years  after  a  stab  wound  of  the  thorax,  is  highly  character- 
istic of  diaphragmatic  hernia.  Inquiry  as  to  trauma  some  months 
or  even  years  previously  is  important,  as  in  several  cases  such  a 
history  has  revealed  the  predisposing  cause  of  the  hernia,  and  thus 
confirmed  a  diagnosis  tentatively  made  from  the  symptoms  alone. 
In  such  cases  the  defect  in  the  diaphragm  may  be  congenital,  and 
the  previous  accident  may  have  been  the  first  cause  of  prolapse  of 
abdominal  viscera  through  the  opening ;  but  no  symptoms  may  have 
been  noted  until  the  recent  strain,  which  produced  incarceration 
or  stranaiulation. 


262     Miscellaneous  Affections  of  Stomach  and  Duodenum. 

Aloreover,  introduction  of  a  stomach  tube  and  distention  of  the 
stomach  with  air  or  liquid  (preferably  the  latter)  will  very  quickly 
change  the  physical  signs  in  the  case  of  diaphragmatic  hernia,  while 
in  pneumothorax  the  thoracic  tympany  and  other  signs  will  not  be 
affected.  The  succussion  splash,  so  characteristic  of  pneumo- 
thorax, may  also  be  elicited  with  great  clearness  in  many  cases  of 
diaphragmatic  hernia;  but  filling  the  stomach  Avith  fluid  will  have 
no  eft"ect  on  this  phenomenon  if  due  to  pneumothorax,  while  it  will 
be  speedilv  abolished  if  it  was  caused  by  fluid  in  an  air-containing 
stomach.  Aspiration  is  to  be  condemned  as  a  method  of  diagnosis, 
the  dangers  of  consequent  septic  pleuritis  or  peritonitis  being  very 
great.  The  distinction  between  eventration  of  the  diaphragm  and 
diaphragmatic  hernia  has  been  referred  to  at  page  257. 

A  further  aid  in  the  diagnosis  of  diaphragmatic  hernia  is  the 
Roentgen  ray.  The  level  of  the  diaphragm  may  thus  be  detected; 
and  by  introducing  bismuth  emulsion  or  a  stomach  tube  filled  with 
mercury  into  the  gastric  cavity,  its  relation  to  the  diaphragm  may 
usually  be  determined. 

Treatment.  There  is  no  question  that  in  cases  of  diaphrag- 
matic hernia  suddenly  developed,  and  of  evident  traumatic  origin, 
immediate  reduction  by  operative  means  offers  the  greatest  pros- 
pect of  recovery.  In  such  cases,  as  in  other  irreducible  hernias  so 
acquired,  the  danger  of  strangulation  is  particularly  great,  and  the 
injury  may  have  produced  lesions  of  the  herniated  organs  (rupture, 
hemorrhage,  etc.)  which  can  be  treated  safely  only  by  surgical 
means.  According  to  Lcnormant,  among  33  cases  of  wounds  of 
the  diaphragm  in  which  no  operation  was  done,  collected  in  1893 
by  von  Frey,  there  were  29  deaths;  and  among  21  unoperated  cases 
analyzed  in  1901  by  de  Font-Reaulx,  there  were  16  deaths,  and  3 
cases  in  which  diaphragmatic  hernia  subsequently  developed.  On 
the  other  iKind,  [.cnormant  liimself  collected  records  of  31  patients 
with  wounds  of  the  dia])hragm  which  were  operated  upon,  and  of 
these  only  7  died.  Although  this  comparison  refers  only  to  stab- 
wounds  and  gunshot  injuries,  the  conditions  in  sul)cutaneous 
rupture  and  in  cases  of  diaphragmatic  hernia  of  sudden  develope- 
ment  are  so  similar  that  the  figures  given  are  ap[)licable  also  to 


Diaphragmatic  Hernia.  263 

injuries  in  which  no  external  wound  exists.  In  cases  where  it 
seems  probable  that  the  hernia  is  of  long  duration,  and  due  to  a  con- 
genital defect  in  the  diaphragm,  delay  in  resorting  to  operation  is 
justifiable;  but  if  the  signs  of  incarceration  or  obstruction  arise,  no 
further  time  should  be  lost — the  hernia  must  be  reduced  by  opera- 
tive means  before  strangulation  has  made  reduction  useless  by  pro- 
ducing oedema,  sloughing,  and  gangrene  of  the  herniated  viscera. 
Guthrie  was  the  first  who  proposed  "to  make  an  opening  in  the 
abdominal  cavity,  and  to  introduce  the  hand  in  order  to  withdraw 
the  bowel  from  the  hernial  opening."  Permann  and  Postempski 
proposed  in  1889,  independently  of  each  other,  the  operation  of 
thoracotomy,  Permann  advocating  it  for  ordinary  cases  of  diaphrag- 
matic hernia,  while  Postempski  urged  it,  and  successfully  employed 
it  in  several  cases,  for  wounds  of  the  diaphragm.  The  first  opera- 
tion (laparotomy)  in  a  non-traumatic  case  appears  to  have  been 
carried  out  in  1879  hy  Bardenheuer  (the  hernia  not  being  discov- 
ered until  postmortem  examination),  while  Postempski  in  1889  did 
the  first  operation  (thoracotomy)  for  stab-wound.  Naumann,  in 
1888,  appears  to  have  been  the  first  to  find  the  hernia  at  operation 
(laparotomy) ;  he  was,  however,  unable  to  reduce  it.  Surgeons  are 
divided  as  to  the  route  by  which  the  rent  in  the  diaphragm  should 
be  approached,  many  preferring  laparotomy,  but  most  are  in  favour 
of  thoracotomy.  Iselin  has  recently  (1907)  tabulated  the  results 
of  35  operations  for  diaphragmatic  hernia,  not  the  result  of  recent 
injuries,*  but  which  became  incarcerated  or  caused  symptoms  of 
obstruction;  27  patients  died,  a  mortality  rate  of  more  than  77  per 
cent.  To  the  cases  collected  by  Iselin  may  be  added  the  reports 
of  eight  other  operations  for  diaphragmatic  hernia,  the  details  of 
which  are  given  at  p.  266.  Adding  these  eight  operations  to  the  35 
previously  collected  by  Iselin,  we  have  a  total  of  43  operations,  with 
34  deaths  and  only  9  recoveries — a  death-rate  of  over  79  per  cent. 
But  if  from  this  reckoning  we  omit  the  13  cases  in  which  the  dia- 
phragmatic hernia  was  not  found  at  operation,  all  of  which  ter- 
minated fatally,  we  have  left  a  total  of  30  completed  operations,  with 
9  recoveries  and  21  deaths,  or  a  death-rate  of  70  per  cent.     Among 

*  Walker's  case,  however,  was  one  of  recent  injury. 


264    Miscellaneous  Affections  of  Stomach  and  Duodenum. 

these  30  patients,  25  were  treated  by  laparotomy,  with  18  deaths,  a 
mortality  of  72  per  cent.,  while  of  the  5  patients  treated  by  thoracot- 
omy, only  3  died,  a  mortality  of  60  per  cent.  As  the  number  of 
cases  involved  is  too  small  to  draw  any  definite  conclusions,  the 
records  of  the  operations  for  stab-wounds  of  the  diaphragm  should 
be  compared,  since  in  these  cases  the  advantages  of  thoracotomy  are 
very  evident.     (See  page  312.) 

In  favour  of  thoracotomy  is  the  fact  that  the  lung  is  already  col- 
lapsed and  the  heart  displaced,  so  that  even  wide  opening  of  the 
pleural  cavity  could  not  materially  increase  the  danger  on  that 
score;  the  greater  accessibliity  of  the  diaphragmatic  opening  also 
would  make  us  prefer  thoracotomy.  More  important,  however, 
than  either  of  these  factors,  is  the  existence  of  negative  pressure  in 
the  unopened  pleura;  the  herniated  viscera  are  thus  held  in  the 
pleural  cavity  by  suction,  and  reduction  by  traction  from  within 
the  abdomen  is  difficult,  if  not  impossible.  Indeed,  the  only  reason 
we  can  see  for  preferring  the  abdominal  route  would  be  the  possi- 
bility of  injury  to  some  abdominal  organs  which  could  not  be 
repaired  from  above.  A  study  of  the  cases,  however,  in  which 
operation  has  been  done  for  diaphragmatic  hernia,  has  convinced 
us  that  in  the  immense  majority  of  cases  thoracotomy  should  be  the 
operation  employed.  The  technique  consists  in  opening  the 
pleural  cavity,  reducing  the  hernia,  repairing  the  defect  in  the  dia- 
phragm, and  closing  the  primary  incision.  In  many  cases  an  inter- 
costal incision,  preferably  in  the  eighth  interspace,  will  give  suffi- 
cient exposure  if  the  ribs  are  forcibly  drawn  asunder  by  strong  re- 
tractors. The  flap  operations  of  Postempski,  Rydygier,  and  others 
are  not  necessary,  and  should  therefore  not  be  employed.  If  the 
simple  intercostal  incision  does  not  give  sufficient  exposure,  one  or 
two  ribs — those  bordering  on  the  primary  incision — may  be  re- 
sected for  a  distance  of  four  or  five  inches.  More  room  than  is  thus 
obtained  is  seldom  requisite.  Should  temporary  resection  of  the 
chest  wall  be  employed,  Rydygier's  operation  is  to  be  preferred  to 
that  of  Postempski.  Rydygier  made  an  intercostal  incision,  en- 
larging the  existing  stalj wound,  and  joined  this  at  its  posterior 
extremity   by  an  incision  made  downward  from  it;  practically  at 


Diaphragmatic  Hernia.  265 

right  angles  to  the  ribs.  The  ribs  are  then  divided  in  the  line  of 
the  second  incision,  and  the  osteoplastic  flap  thus  formed  is  turned 
downward  and  forward,  the  elastic  costal  cartilages,  which  are 
not  divided,  acting  as  a  hinge.  In  Postempski's  operation  the  ribs 
are  divided  front  and  back,  and  the  flap  thus  made  is  turned  di- 
rectly downward.  In  some  instances  the  flap  formed  by  Postemp- 
ski's method  has  sloughed.  The  use  of  hot  moist  compresses  of 
gauze,  to  isolate  the  operative  field  from  the  upper  portion  of  the 
pleural  cavity  and  the  lung,  is  of  great  assistance,  and  lessens  any 
symptoms  which  may  arise  from  the  operative  pneumothorax.  In 
cases  of  stabwound,  or  of  traumatic  hernia,  great  care  should  be 
taken  to  repair  any  injury  of  the  stomach,  colon,  or  other  structures 
found  in  the  pleural  cavity.  As  such  injuries  are  in  the  upper  or 
posterior  walls  of  the  stomach,  they  are  readily  accessible  by  the 
transpleural  route,  but  are  very  difficult  of  access  or  totally  inac- 
cessible by  laparotomy.  After  all  ruptures  or  perforations  are  re- 
paired, the  herniated  organs  are  to  be  reduced,  and  the  breach  in 
the  diaphragm  sutured.  If  this  be  very  large,  the  omentum  may 
be  attached  to  its  margins,  by  sutures;  but  usually  it  has  been  possi- 
ble to  close  it  without  the  use  of  omentum.  It  is  generally  safer  to 
drain  the  pleural  cavity  for  a  few  days;  immediate  closure  of  the 
thoracic  wound  without  drainage  has  usually  resulted  in  widespread 
subcutaneous  emphysema,  or  in  the  developement  of  haemothorax 
or  empyema.  In  Riegner's  patient  with  stab  wound  of  the  dia- 
phragm, the  abdomen  was  opened  after  repairing  the  herniated 
organs  and  the  diaphragm  by  thoracotomy;  but  as  no  abdominal 
lesion  was  found,  the  laparotomy  wound  was  immediately  closed. 
While  it  is  certainly  safer  to  explore  the  abdomen  if  there  is  a  prob- 
ability of  further  lesions,  in  most  cases  such  good  exposure  has  been 
obtained  by  means  of  thoracotomy  that  no  secondary  laparotomy 
has  been  employed. 

If  no  diagnosis  other  than  intestinal  obstruction  has  been  made, 
laparotomy  will  be  the  operation  employed;  but  if  reduction  of  the 
hernia  prove  difficult  from  below,  the  surgeon  should  not  hesitate 
to  create  a  pneumothorax  by  means  of  thoracotomy,  as  has  been 
done  by  Dennis  and  others,  to  relieve  the  negative  pressure  within 
the  pleural  cavity. 


266    Miscellaneous  Affections  of  Stomach  and  Duodenum. 

OPERATIONS  FOR  DIAPHRAGMATIC  HERNIA 
ADDITIONAL  TO  ISELIN'S  TABLES. 

(Deutsch.  Zeit.  'f.  Chir.,  1907,  Ixxxviii,  190.) 

I.  Hernia  found  only  at  autopsy. 

1.  Whiting  (cited  by  Kelly,  Proc.  Pathol.  Soc.  Phila.,  1900, 
256).  Diagnosis:  intestinal  obstruction  of  5  days  dura- 
tion. Exploratory  laparotomy.  Patient  died  on  operat- 
ing table  before  lesion  could  be  determined. 

2.  Patel  (Revue  de  Chir.,  1908,  i,  861).  Vague  gastric 
symptoms  for  two  years;  signs  of  intestinal  obstruction 
for  eight  days.  Exploratory  laparotomy,  with  false  anus 
in  csecum.     Death  in  eight  days.     Diagnosis  at  autopsy. 

II.  Hernia  found  at  operation. 

(A)  Laparotomy. 

1.  Dennis  (St.  Paul  Med.  Jour.,  1905,  vii,  736).  Diag- 
nosis: obstruction  close  to  stomach.  Impossible  to 
reduce  hernia  by  laparotomy,  until,  by  resection  of  one 
rib,  pleura  was  opened ;  negative  pressure  within  thorax 
being  thus  overcome,  hernia  was  easily  reduced.  Dia- 
phragm not  sutured,  but  defect  walled  off  with  gauze 
through  thoracotomy  wound.  Abdomen  closed.  Re- 
covered after  empyema. 

2.  Gordon  (Annals  of  Surgery,  1907,  i,  680).  Stabbed 
six  years  before.  Diagnosis:  intestinal  obstruction. 
Hour-glass  stomach  found  in  thorax,  reduced;  gastro- 
enterostomy. Diayjhragm  not  sutured.  Died  in  four 
days.  At  autopsy  part  of  stomach  was  found  to  have 
again  passed  into  thorax. 

3.  Mackenzie  and  Battle  (Lancet,  1901,  ii,  1582). 
Stabbed  seven  or  eight  years  before.  Diagnosis:  intes- 
tinal obstruction.  Hernia  reduced  by  laparotomy; 
diaphragm  not  sutured.  No  drain.  Died  in  three 
days. 

4.  McRae  (Trans.  South.  Surg,  and  Gyn.  Assoc,  1894, 
vii,  77).  Stabbed  eight  months  before.  Stomach  was 
detected  beneath  intercostal  scar  as  tympanitic  swelling. 
Diagnosis:  strangulated  diaphragmatic  hernia.  Op- 
eration five  days  after  on.set.  Hernia  reduced  by  lapa- 
rotomy; all  structures  found  gangrenous.  Died  in  eight 
hours. 


Diaphragmatic  Hernia.  267 

5.  Mixter  (Bost.  Med.  and  Surg.  Jour.,  1900,  cxlii,  301). 
Sudden  onset  after  violent  exertions.  Diagnosis:  intes- 
tinal obstruction.  Hernia  reduced  by  laparotomy. 
Gauze  packs  to  diaphragm,  on  account  of  collapse  of 
patient.  Died  in  fourteen  hours. 
(B)  Thoracotomy. 

I.  Freeman  (Trans.  Amer.  Surg.  Assoc,  1900,  xviii,  255). 
Recent  hernia  from  crush.  Reduced  and  diaphragm 
sutured  bv  thoracotomy.     Died. 


REFERENCES. 

Bardenheuer:   Cited  by  Iselin,  loc.  infra  cit. 

Cranwell:   Revue  de  Chir.,  1908,  xxxvii,  33. 

Deitz:   Cited  by  Lacher,  Gaz.  Med.  de  Strasbourg,  1884,  xliii,  loi. 

Grenier  de  Cardenal:   Jour,  de  Med.  de  Bordeaux,  1903,  xxxiii,  222. 

Grosser:  Wien.  klin.  Woch.,  1899,  xii,  655. 

Guthrie:  Cited  by  John  Wood,  Internat.  Encyclop.  of  Surgery  (Ash- 
hurst),  Revised  Ed.,  New  York,  1888,  vi,  203. 

Iselin:   Deutsch.  Zeit.  f.  Chir.,  1907,  Lxxxviii,  190. 

Jaffe:   Trans.  Path.  Soc.   London,  1893-4,  xlv,  224. 

Lacher:  Deutsch.  Arch.  f.  khn.  Med.,  1880,  xxvii,  268. 

Lenormant:   Revue  de  Chir.,  1903,  xxvii,  617. 

Naumann:  Hygiea,  Festband,  1888,  No.  15;  cited  by  Blum  and  Om- 
bredonne.  Arch.  Gen.  de  Med.,  1896,  clxxxvii,  186. 
Obs.  C.  and  E. 

Patel:   Revue  de  Chir.,  1908,  i,  861. 

Perman:   Cited  by  Lenormant,  loc.  supra  cit. 

Postemski:   Brit.  Med.  Jour.,  1889,  i,  1016. 

Warren:   Internat.  Textbook  of  Surgery,  Phila.,  1903,  ii,  351. 


CHAPTER   XI. 
MALIGNANT  DISEASES  OF  THE  STOMACH:   CARCINOMA. 

Cancer  of  the  stomach  is  a  disease  of  frequent  occurrence.  From 
25  to  40  per  cent,  of  all  cancers  in  the  body  are  primary  in  the  stomach. 
Statistics  (Bryant)  show  that  in  Bakimore  there  are  over  two  hun- 
dred deaths  annually  from  cancer;  that  in  Boston  there  are  over 
three  hundred,  in  Philadelphia  nearly  five  hundred,  and  in  New  York 
nearly  nine  hundred  deaths  every  year  from  some  form  of  cancer.  Of 
these  deaths,  more  than  one-fourth,  and  perhaps  almost  a  half,  are 
directly  due  to  cancer  of  the  stomach.  Fenwick  (loc.  cit.,  p.  81) 
states  that  over  13  per  cent,  of  deaths  due  to  diseases  of  the 
digestive  organs  are  caused  by  carcinoma  of  the  stomach.  Dowd 
says  that  the  United  States  Census  Report  for  1900  recorded  9000 
deaths  from  cancer  during  that  year;  that  31  per  cent,  of  fatal  can- 
cers were  in  the  stomach;  that  probably  (as  we  shall  see  later)  many 
cancers  of  the  liver  and  the  abdomen  were  primarily  gastric;  and  that 
many  cases  recorded  as  gastritis  and  allied  diseases  were  really 
carcinomatous  in  nature. 

^Etiology  and  Pathology. — The  cause  of  cancer  is  unknown. 
That  it  is  caused  by  some  form  of  micro-organismal  life  is  in- 
ferred by  some  pathologists ;  but  beyond  such  an  inference  even  the 
most  enthusiastic  pathologists  will  not  go.  Direct  curative  treat- 
ment is  therefore  at  present  impossible. 

In  studying  cancer  of  the  stomach  both  the  predisposing  and 
exciting  causes  of  its  existence  must  be  considered,  and  especially 
is  this  true  of  the  predisposing  causes.  As  will  be  shown  under  the 
discussion  of  Treatment,  the  surgery  of  the  future  will  probably  deal 
directly  with  some  of  these  predisposing  causes. 

Race.  Carcinoma,  whcllitT  of  the  stomacli  or  other  region  of 
the  I.)ody,  is  peculiarly  an  affection  of  the  Caucasian  race.  Accord- 
ing to  Bainbridge,  the  black  races  seem  to  be  almost  immune,  the 

268 


^Etiology.  269 

yellow  races  are  more  vulnerable,  while  the  white  races  are  most 
liable  to  its  presence. 

Sex  has  very  little  influence  on  the  occurrence  of  the  disease. 
Among  1303  cases,  Fox  observed  680  men  and  623  women;  in  2214 
cases  studied  by  Welch,  1233  were  males,  and  981  females.  Fen- 
wick,  after  c|uoting  these  figures,  gives  results  of  his  own  researches: 
among  3679  post  mortem  examinations  of  gastric  cancer,  2162  were 
males,  and  151 7  females,  a  proportion  of  rather  less  than  6  to  4. 
But  as  Fenwick  points  out,  it  is  to  be  remembered  that  men  form 
a  larger  proportion  of  hospital  patients  and  of  the  subjects  of  post- 
mortem examination  than  do  women,  so  that  even  these  figures 
probably  exaggerate  the  relative  frequency  of  gastric  carcinoma  in 
men. 

Age.  Cancer  of  the  stomach  occurs  usually  in  patients  between 
the  ages  of  forty  and  seventy  years  (about  80  per  cent,  of  all  gastric 
carcinoma  cases).  It  is  rare  below  the  age  of  twenty  and  over  that 
of  eighty  years.  Bernoulli  reports  three  cases  that  came  under  his 
own  observation  in  which  there  was  carcinoma  of  the  stomach  or 
rectum  in  patients  aged  fifteen,  seventeen,  and  eighteen  years  re- 
spectively. He  also  collected  50  cases  from  the  literature  in  which 
carcinoma  had  been  found  in  the  young,  13  of  them  having 
the  stomach  as  the  site  of  the  cancer.  In  one  instance  the  cancer 
of  the  stomach  was  evidently  congenital. 

Trauma  may  determine  the  localization  of  carcinoma  in  the 
stomach.  Ropke  found  trauma  a  direct  cause  of  gastric  carcinoma 
in  2  out  of  79  cases  observed.  Lacerations  of  the  mucosa,  from 
acute  distension  of  the  stomach,  have  been  suggested  by  Strassmann 
and  others  as  the  starting  point  of  gastric  ulcers  and  cancers.  (See 
p.  70.) 

Dyspepsia.  There  is  no  factor  which  of  late  years  has  attracted 
so  much  attention  as  a  predisposing  cause  of  gastric  cancer  as  has 
long  continued  indigestion.  A  more  intimate  knowledge  of  these 
cases  will  probably  show  that  much  of  the  digestive  disturbance 
is  due  to  the  presence  of  an  ulcer  or  its  sequels  (cicatrices,  stenosis 
of  the  pylorus,  etc.).  "Chronic  gastric  irritation"  possibly  would 
be  a  better  term  to  use  to  denote  this  predisposing  factor  in  the 


2/0       Malignant  Diseases  of  the  Stomach:   Carcinoma. 

aetiology  of  carcinoma  of  the  stomach.  Thus  Mumford  and  Stone 
traced  60  patients  who  had  been  treated  at  the  Massachusetts  Gen- 
eral Hospital  for  "chronic  indigestion,"  and  who  subsequently 
died.  Of  these  no  less  than  half  died  of  gastric  carcinoma.  These 
writers  further  made  a  study  of  50  patients  with  gastric  carcinoma  and 
learned  that  in  no  less  than  41  of  the  50  patients  there  was  "a  his- 
tory either  of  ulcer  or  of  long-continued  digestive  disturbance,  of 
which  the  exact  nature  could  not  be  ascertained."  Mayo  in  1905 
found  a  history  of  ulcer  or  other  disease  in  36  per  cent,  of  his 
patients  with  cancer  of  the  stomach,  and  detected  clear  evidence 
of  cancer  having  developed  on  ulcer  in  30  per  cent,  of  the  last  forty 
pylorectomies  and  partial  gastrectomies  performed;  in  1907  he  re- 
ported that  the  clinical  history  of  69  patients  with  gastric  cancer, 
and  pathological  examination  of  the  specimens  removed  from  them 
by  gastrectomy,  during  1905  and  1906,  made  it  clear  that  in  54  per 
cent,  the  cancer  had  its  origin  in  an  ulcer.  Moynihan  (1906)  noted  a 
history  of  gastric  ulcer  or  chronic  indigestion  in  27  out  of  45 
patients  with  cancer  of  the  stomach  (60  per  cent.);  while  among  22 
patients  with  gastric  carcinoma  so  far  advanced  as  to  be  operable 
only  by  gastro-enterostomy,  no  less  than  16,  or  over  72  per  cent.,  gave 
such  a  history.  Jedlicka  quotes  Ssapesko  as  stating  that  among  100 
cases  of  gastric  carcinoma  only  10  were  found  in  which  the  cancer 
was  not  engrafted  on  a  preceding  ulcer.  Hayem  found  that  21  out 
of  94  specimens  of  gastric  carcinoma  collected  in  his  service  during 
fifteen  years  evidently  had  originated  as  degenerated  ulcers.  Fur- 
ther statistics  could  no  doubt  be  quoted;  they  would  merely  serve 
to  emphasize  the  point  on  which  we  insist,  that  chronic  gastric  dys- 
pepsia is  the  chlej  predisposing  cause  oj  cancer  oj  the  stomach. 

We  know  that  cancer  of  the  stomach  presents  clinically  two 
forms.  In  one,  a  patient  past  middle  life,  without  having  suffered 
previously  from  indigestion,  suddenly  loses  appetite,  especially  for 
meats,  grows  progressively  weaker  and  more  emaciated,  developes 
epigastric  pain  and  possibly  a  palpable  mass,  becomes  subject  to 
vomiting  spells  every  few  days,  which  bring  u])  a  (juantily  of  coffee- 
ground  material,  foul  smelling  and  fermented,  and  quickly  devel- 
opes the  cancerous  cachexia.     This  is  the  classical  picture  of  gastric 


i^^tiology.  271 

carcinoma,  and  it  is  still  seen;  but  it  is  of  rarity  when  compared  with 
that  other  course  of  developement  which  we  have  begun  to  appre- 
ciate only  in  the  last  few  years.  Gastric  carcinoma  appears  with 
sudden  onset  in  not  more  than  ten  per  cent,  of  cases.  The  second, 
and  much  more  frequent  course,  is  found  in  patients  w^ho  have  been 
life-long  sufferers  from  dyspepsia.  Medical  treatment  has  at  times 
given  relief,  but  the  indigestion  recurs  again  and  again.  Appetite 
may  be  preserved,  but  digestion  is  torture;  so  abstemiousness  be- 
comes second  nature.  There  may  or  there  may  not  have  been 
some  period  when  gastric  ulcer  was  suspected  or  actually  diagnosti- 
cated. Usually  there  have  been  no  very  definite  symptoms,  and  the 
patient  has  been  treated  for  chronic  gastritis.  Finally  these  pa- 
tients die;  and  at  autopsy  a  v/ide-spreading  epitheliomatous  ulcer 
is  found. 

The  histological  changes  by  which  simple  ulcer  becomes  con- 
verted into  carcinoma  have  been  particularly  investigated  by  the 
French  pathologists.  Although  their  theories  are  not  unreservedly 
accepted  by  other  writers,  they  seem  to  merit  a  short  description 
in  this  place,  especially  as,  when  considered  in  this  light,  these 
changes  may  be  regarded  as  in  the  nature  of  predisposing  causes. 
Hayem  described,  a  number  of  years  ago,  adenomata  in  the 
pyloric  region,  which  he  characterized  as  Brunnerian  in  type 
— that  is  to  say,  resembling  the  glands  of  Brunner,  which  are 
found  in  the  duodenum,  and  which  are  distinguished  from  the 
gastric  glands  by  their  situation  wdthin  the  submucosa,  the  gas- 
tric glands,  as  is  well  known,  never  extending '  below  the  mus- 
cularis  mucosae.  These  adenomata  of  Brunnerian  type,  occurring 
in  the  pyloric  region  of  the  stomach,  are  clearly  neoplastic  in  char- 
acter, and  are  regarded  by  Hayem  as  an  early  stage  of  carcinoma- 
tous transformation.  Menetrier  has  more  recently  (iqco)  elab-. 
ourated  his  earlier  studies  along  the  same  lines.  He  studied 
microscopically  15  ulcers  (11  gastric  and  4  duodenal)  in  various 
stages  of  developement,  but  all  in  activity,  the  cicatrization  which 
existed  in  some  being  incomplete.  Of  the  11  gastric  ulcers,  4 
showed  no  traces  of  adenomatous  changes;  6  showed  clear  adeno- 
matous changes;  and  i  had  progressed  to  the  stage  of  actual  carcin- 


2/2       Malignant  Diseases  of  the  Stomach:   Carcinoma. 

omatous  transformation.  Of  the  4  duodenal  ulcers,  3  were 
clearly  adenomatous,  and  i  had  no  trace  of  such  change.  It  is  to 
be  noted  that  of  the  gastric  ulcers  (4  in  number)  which  showed  no 
adenomatous  change,  3  were  ulcers  which  had  been  arrested  sud- 
denly in  the  course  of  their  developement  (two  patients  having  died 
suddenly  of  hemorrhage,  and  one  of  perforation) — so  that  they  had 
not  been  so  long  subjected  to  irritation  from  the  gastric  contents; 
and  the  only  duodenal  ulcer  which  showed  no  adenomatous  change 
was  a  recent  ulcer  in  a  tuberculous  woman,  not  a  long-standing 
chronic  ulcer,  as  were  all  those  which  did  show  this  change.  Mene- 
trier  sums  up  his  theory  of  carcinomatous  transformation  in  this 
way:  First  stage — this  is  purely  inflammatory;  there  is  a  chronic 
gastritis,  and  the  cells  lining  the  glands  lose  their  special  and  dis- 
tinctive features  (the  histological  picture  is  simplified);  and  the 
"acid"  cells  disappear.  Second  stage — adenomatous  in  character; 
the  proliferating  glands,  deprived  of  their  characteristic  elements, 
become  more  contorted  and  convoluted:  the  cells  increase  in  num- 
ber; cysts  form  as  the  result  of  obstruction  of  the  gland  ducts  by 
proliferation  of  their  lining  cells.  Third  stage — epitheliomatous 
in  character;  the  cell  groups  break  through  the  muscularis  mucosae, 
and  finally  are  found  lying  free  among  the  connective  tissues  of  the 
gastric  walls. 

Exciting  Causes. — Ewing  elabourately  discusses,  in  regard  to 
carcinoma,  the  parasitic  theory,  the  theory  of  cell  autonomy,  and 
the  modern  biological  and  chemical  study.  He  "shuts  the  door'^ 
against  any  theory  of  a  specific  cancer  parasite,  nor  will  he  concede 
that  a  malignant  tumor  requires  a  continuous  irritant  propagated 
by  micro-organisms  throughout  its  course.  He  claims  that  cell 
autonomy  could  account  for  the  phenomenal  growth  of  malignant 
tumors,  although  an  external  stimulus  may  be  required,  l)ut  not  of 
necessity.  He  claims  that  the  chief  hope  for  the  reduction  of  the 
mortality  from  cancer  depends  upon  the  earlier  recognition  of  the 
so-called  pre-cancerous  stage  of  the  disease  and  the  elimination  of 
some  of  the  factors.  Otlicr  ])athologists,  howewr,  believe  the  para- 
sitic theory  will  eventually  explain  the  cause  of  cancer.  Odier 
looks  ujjon  cancer  as  a  constitutional  rather  than  a  local  disease. 


Clinical  Pathology. 


273 


He  recognizes  as  " cancerogene^'  a  substance  (the  X-siibstance  of 
Ehrlich)  which  is  produced  by  the  organism  without  cessation.  Ac- 
cording to  his  theory,  all  that  is  necessary  to  prevent  the  growth  of 
cancer  is  to  abolish  this  " cancerogene^',  which  he  proposes  to  ac- 
complish by  increasing  the  glycolytic  ferment,  as  glycogen  seems 
to  be  indispensable  to  the  growth  of  the  cancer. 

Clinical  Pathology. — Situation.  Carcinoma  of  the  stomach 
is  found  in  the  pyloric  region  in  from  57  (Luton)  to  65  per  cent. 
(Fen  wick)  of  cases.  The  following  table  from  Fen  wick  shows  the 
location  of  the  growth  in  1S50  cases  collected  by  him: 


Cases 

Per  cent,  of  whole  No. 


^ 

"2 

0 

s 

w  > 

|5 

< 

< 
u 

1 

6 

1^  ^ 

< 

0 

z 

r4 

1072 

214 

183 

Q4 

52 

41 

29 

III 

5« 

ii-S 

9.8 

s 

2.8 

2.2 

1-5 

6 

So 


54 


2.9 


Fenwick  concluded,  from  these  figures,  "that  in  79.4  per  cent., 
or  in  about  four-fifths  of  all  cases,  carcinoma  commences  in  the' 
comparatively  small  strip  of  tissue  which  extends  from  one  orifice 
to  the  other  along  the  upper  margin  of  the  stomach,  and  that  its 
percentage  rapidly  diminishes  the  further  we  proceed  from  the 
pyloric  valve." 

The  frequency  with  which  carcinoma  is  found  in  corresponding 
situations  on  the  anterior  and  posterior  walls  of  the  stomach,  ex- 
tending down  as  a  saddle  from  the  lesser  curvature,  also  bears  a 
striking  resemblance  to  the  ulcers  which  occur  in  this  position ;  in 
both  cases  the  involvement  of  both  walls  is  to  be  attributed  rather 
to  analogous  causes,  such  as  a  like  blood  supply,  than  to  any  fancied 
infection  from  a  growth  on  one  wall  producing  a  similar  growth 
on  the  opposite. 

Histological  Structure.  Microscopically,  three  types  of  gas- 
tric cancer  are  recognized:  (i)  A  tumor  composed  of  spheroidal 
cells  like  those  normally  lining  the  gastric  tubules  (spheroidal 
celled  carcinoma);  (2)  a  tumor  composed  of  more  or  less  columnar 
or  cylindrical  cells,  similar  to  those  normally  lining  the  pyloric 
18 


274       Malignant  Diseases  of  the  Stomach:   Carcinoma. 

glands  (cylindrical  celled  or  adeno-carcinoma);  (3)  a  tumor  whose 
chief  characteristic  is  myxomatous  degeneration  of  epithelial  cells 
and  stroma  (colloid  carcinoma),  which  may  be  the  result  of  changes 
in  either  the  spheroidal  celled  or  the  adenomatous  carcinoma. 
Finally  these  tumors  are  described  as  scirrhus  or  medullary  (en- 
cephaloid)  according  as  they  are  rich  or  not  in  fibrous  tissue  as  com- 
pared with  the  cellular  elements  present. 

There  does  not  appear  to  be  sufficient  material  for  it  to  be  pos- 
itively decided  which  variety  of  carcinoma  occurs  most  frequently. 
Brinton's  figures  indicated  that  72  per  cent,  of  gastric  carcinomata 
were  of  the  scirrhous  variety;  but  more  recent  statistics  collected 
by  Brinton's  method  tend  to  show  that  the  medullary  forms  prepon- 
derate. When  histological  examination  shall  have  been  recorded 
in  a  larger  number  of  cases,  it  may  become  possible  to  say  whether 
the  spheroidal  celled  or  the  cylindrical  celled  variety  is  the  more 
frequent.  Colloid  carcinoma  is  of  course  the  result  of  secondary 
change,  and  is  oftentimes  not  to  be  detected  except  on  microscop- 
ical examination.  Fenwick  studied  115  cases  of  gastric  carcinoma 
microscopically,  and  found  that  63.5  per  cent,  were  described  as 
spheroidal  celled,  28.6  per  cent,  as  cylindrical  celled,  and  7.8  per 
cent,  as  exhibiting  signs  of  colloid  degeneration. 

Metastasis.  Metastasis  occurs  early  in  carcinoma  of  the 
stomach,  but  for  a  reasonable  time  this  metastasis  is  confined  to  the 
immediately  adjacent  lymph  nodes.  According  to  Mumford,  in 
from  4  to  10  per  cent,  of  those  patients  with  the  perigastric  lymph 
nodes  palpably  enlarged,  no  carcinomatous  invasion  of  these  lymph 
nodes  exists.  The  lymphatics  of  the  stomach  have  already  been 
discussed  (p.  13).  Our  knowledge  of  these  lymphatic  areas  is  due 
almost  entirely  to  the  classical  investigations  of  Cuneo;  and  Hart- 
mann  was  the  first  to  make  practical  applications  of  his  teachings, 
in  performing  excision  for  gastric  cancer.  More  recent  observa- 
tions have  invalidated  the  conclusions  of  Cundo  in  some  anatomical 
details,  but  the  practical  lessons  to  be  drawn  from  Cuneo's  re- 
searches are  in  no  way  affectefl.  'I'hc  cliicf  of  these  lessons  is  that 
carcinoma,  beginning,  as  it  usually  docs,  along  the  lesser  curvature 
close  to  the  pylorus,  invades  first  the  lymph  nodes  lying  along  the 


Metastasis.  275 

lesser  curvature;  and  that  this  chain  of  lymph  nodes  is  very  quickly 
invaded  even  up  to  the  coronary  group  of  nodes  surrounding  the 
coronary  artery  close  to  the  cardiac  orifice.  From  this  fact  it  is 
evident  that  radical  operations  for  gastric  cancer  must  remove  prac- 
tically the  entire  lesser  curvature  of  the  stomach.  Moreover,  as 
soon  as  the  carcinoma  is  at  all  extensive,  it  is  found  that  the  lymph 
nodes  in  the  gastro-colic  omentum,  for  a  variable  distance  away  from 
the  pylorus,  are  involved.  Hence  Hartmann's  line  for  gastrectomy 
was  made  to  pass  from  the  coronary  artery  to  a  point  nearly  directly 
below  it,  on  the  greater  curvature  of  the  stomach.  A  third  point  of 
the  greatest  importance  is  that  whereas  the  carcinomatous  invasion 
extends  rapidly  and  for  an  indefinite  distance  away  from  the  pyloric 
region  of  the  stomach,  it  invades  the  duodenum  only  rarely.  The 
removal  of  the  first  inch  of  the  duodenum  will  nearly  invariably 
enable  the  surgeon  to  get  safely  beyond  the  limits  of  the  malignant 
growth.  It  is  a  well-recognized  fact  that  the  palpable  induration 
of  the  gastric  cancer  stops  with  the  area  of  mucosa  affected,  but 
that  in  the  submucosa  the  invasion  will  have  advanced  considerably 
further:  hence  the  necessity  of  cutting  wide  of  the  indurated  mar- 
gins of  the  carcinoma.  From  Borrmann's  studies  of  resected 
stomachs  from  the  clinique  of  Mikulicz  it  is  evident  that  these  in- 
cisions must  be  made  from  5  to  8  cm.  (two  to  three  and  a  half 
inches)  away  from  the  macroscopical  tumor  on  the  cardiac  side  of 
the  growth,  and  from  1.5  to  2  cm.  (one-half  to  three-fourths  of  an 
inch)  from  it  on  the  intestinal  side. 

While  Cuneo  found  that  the  presence  of  lymph  nodes  beneath 
the  pylorus  was  very  unusual,  Jamieson  and  Dobson  found  them 
quite  frequently  present,  thus  confirming  the  observations  of  Lenge- 
mann,  who  noted  their  presence  in  60  per  cent,  of  the  stomachs  ex- 
amined. But  Cuneo's  conclusion  that  the  removal  of  these  glands 
is  rarely  necessary,  is  paralleled  by  Jamieson's  and  Dobson's  asser- 
tion that  their  removal  would  be  extremely  difficult,  if  not  impos- 
sible, and  that  it  probably  is  very  rarely  accomplished.  And, 
while  Cuneo  thought  that  the  pylorus  and  the  whole  of  the  lesser 
curvature  drained  into  the  lower  coronary  group  of  glands  as  they 
are  named  by  Jamieson  and  Dobson,  these  writers  found  that  in 


276       Malignant  Diseases  of  the  Stomach:   Carcinoma. 

not  a  few  instances  lymph  channels  may  be  traced  which  pass 
directly  past  these  glands,  and  empty  into  the  right  supra-pancreatic 
glands  lying  along  the  trunk  of  the  hepatic  artery.  The  disheart- 
ening conclusion  is  reached  by  Jamieson  and  Dobson,  as  a  result 
of  their  studies,  that  "except  as  a  mere  matter  of  chance  no  opera- 
tion for  gastric  carcinoma  can  be  a  radical  one  when  once  malig- 
nant emboli  have  commenced  to  reach  the  lymphatic  glands.  The 
only  reason,"  they  add,  "for  removing  as  many  of  the  diseased  glands 
as  possible,  is  the  hope  that  once  the  primary  growth  and  the  ma- 
jority of  the  glands  have  been  removed,  the  remaining  glands 
may  be  able  to  deal  with,  and,  perhaps,  destroy,  the  malignant 
elements  they  contain;  of  this  process,  however,  we  know  little  or 
nothing." 

Apart  from  the  lymph  nodes,  metastasis  of  gastric  carcinoma 
occurs  most  frequently  to  the  liver,  which  is  affected  in  one-third 
of  cases  examined  at  autopsy.  The  malignant  invasion  occurs 
along  the  radicles  of  the  portal  vein.  In  scirrhous  carcinoma,  and 
in  all  forms  which  cause  marked  pyloric  stenosis,  invasion  of  the 
liver  is  unusual.  The  great  omentum  becomes  invaded  by  can- 
cerous nodules  almost  as  frequently  as  the  liver,  but  ascites  is  a 
rather  unusual  accompaniment  The  lungs,  the  intestines,  and 
other  internal  organs  are  as  a  rule  invaded  only  very  late  in  the 
disease.  The  left  supraclavicular  lymph  nodes  are  sometimes 
affected  in  the  last  stages  of  gastric  carcinoma,  but  it  is  worthy  of 
note  that  these  nodes  frequently  have  been  found  enlarged,  without 
being  affected  by  any  cancerous  change  which  could  be  detected 
even  by  microscopical  examination. 

Extension  by  Contiguity.  Oastric  carcinoma  is  the  most  fre- 
quent cause  of  internal  gastric  fistula.  Of  66  cases  referred  to  by 
Lieblein  and  Hilgenreiner,  in  which  a  gastro-colic  fistula  was  due  to 
disea.se  of  the  stomac  h,  it  was  caused  by  carcinoma  in  47.  The 
gall  bladfler  is  much  less  often  in\()l\cd.  In  any  case,  it  is  not  very 
unusual  for  a  fistula  thus  formed  to  close  again  spontaneously 
before  death,  by  the  developement  of  further  perigastric  adhesions. 
The  pancreas,  the  liver,  and,  very  rarely,  the  spleen,  may  be  invaded 
by  direct  extension  of  the  growth.      I'erforation  of  the  diaphragm, 


Secondary  Gastric  Carcinoma.  277 

and  even  the  formation  of  a  gastric  cutaneous  fistula,  is  sometimes 
observed.  Fenwick  refers  to  22  instances  of  this  last  condition,  3 
of  which  came  under  his  own  observation  at  autopsy.  According 
to  Lieblein  and  Hilgenreiner,  cancer  is  a  more  frequent  cause  of 
gastric  cutaneous  fistula  than  is  gastric  ulcer.  They  collected  26 
cases  due  to  the  former,  and  found  only  17  caused  by  ulcer.  The 
reader  is  referred  to  this  valuable  monograph  for  further  statistics 
of  gastric  fistulae.     (See  also  p.  435.) 

Perforation  of  gastric  cancer  into  the  free  peritoneal  cavity  is 
very  rare,  existing  in  only  3  per  cent,  of  the  fatal  cases  studied  by 
Fenwick.  Sometimes  a  subacute  perforation  occurs,  with  the 
formation  of  a  perigastric  abscess;  and  this,  by  subsequent  rupture, 
may  cause  death  from  peritonitis.  Such  a  case,  recorded  by  Dr. 
Ashhurst,  has  already  been  described  in  connection  with  Hour- 
glass Stomach.     (See  p.  189.) 

Secondary  gastric  carcinoma  is  of  little  surgical  interest.  It 
is  found  in  6  or  7  per  cent,  of  autopsies  on  patients  with  gastric  can- 
cer (Hale  White;  Fenwick),  and  is  usually  (73.6  per  cent,  according 
to  Fenwick)  due  to  direct  extension  from  some  neighbouring  organ, 
such  as  the  pancreas,  transverse  colon,  gall-bladder,  uterus  (through 
omentum),  oesophagus,  etc.;  less  frequently  (21  per  cent.)  it  is  sec- 
ondary to  cancer  of  the  tongue,  mouth,  pharynx,  upper  oesophagus, 
etc.,  being  then  perhaps  due,  as  suggested  by  Klebs,  "to  the  detach- 
ment of  particles  of  growth,  which  are  swallowed,  and  subsequently 
become  engrafted  upon  the  gastric  mucous  membrane."  (Fen- 
wick.) Engelhorn  calls  attention  to  gastric  carcinoma  occurring 
simultaneously  with,  or  secondary  to,  carcinoma  of  the  ovary.  He 
has  studied  13  cases  from  Doderlein's  clinique,  and  suggests  the 
propriety  of  examining  the  patient  for  gastric  carcinoma  whenever 
malignant  disease  exists  in  the  ovary.  True  metastases  (from 
mammary  gland,  testicle,  uterus,  kidney,  etc.)  were  found  in  5  per 
cent,  of  Fenwick's  cases,  and  are  usually  accompanied  bymetastatic 
invasion  of  the  lungs,  liver,  etc.  Hence  surgical  treatment  is  rarely 
required  in  secondary  carcinoma  of  the  stomach. 

One  patient  who  was  operated  on  by  Dr.  Deaver  by  partial  gas- 
trectomy for  carcinoma,  returned  30  months  later  with  a  large  pelvic 


2/8       Malignant  Diseases  of  the  Stomach:   Carcinoma. 

tumor.  At  the  operation  this  was  found  to  be  a  sohd  tumor  of  the 
ovary;  it  was  thought  to  be  carcinomatous;  but  after  microscopical 
study  Dr.  A.  O.  J.  Kelly  pronounced  it  a  sarcoma.  There  w^as  no 
recurrence  of  carcinoma  in  the  stomach  or  elsewhere. 

Symptoms. — Although  we  have  already  (p.  270)  pointed  out 
the  characteristics  of  the  two  main  groups  of  cases  in  which  cancer 
of  the  stomach  is  found,  it  is  proper  to  dwell  more  at  length  upon 
certain  individual  symptoms.  And  in  doing  this,  it  is  well  to  pre- 
mise what  is  known  to  all  who  have  anything  to  do  with  these  pa- 
tients, that  early  diagnosis  of  carcinoma  of  the  stomach  is  so  difficult 
as  to  be  usually  impossible;  that  is  to  say,  an  accurate,  assured 
diagnosis,  based  on  scientific  reasons,  and  not  a  mere  supposition 
nor  a  happy  guess  that  the  affection  is  malignant  in  nature.  Even 
so  distinguished  an  authority  as  Boas  has  recently  come  to  the  same 
melancholy  conclusion. 

The  descriptions  heretofore  given  in  text  books  and  monographs 
on  diseases  of  the  stomach  are  concerned  almost  wholly  with  the 
second,  smaller  group  of  cases,  in  which  the  symptoms  were  sub- 
acute or  even  acute  in  onset — this  being  the  only  group  of  cases  of 
gastric  cancer  previously  recognized.  But  as  we  have  repeatedly 
pointed  out,  it  is  becoming  more  and  more  widely  appreciated  that 
this  class  forms  only  a  small  proportion,  perhaps  one-tenth,  of  all 
patients  with  gastric  cancer;  and  that  the  far  larger  group  will  ulti- 
mately be  found  to  consist  of  those  patients  who  are  sufferers  from 
chronic  gastric  dyspepsia.  These  patients  present  the  symptoms, 
already  noted  in  the  section  on  gastric  ulcer;  and  it  is  needless  to 
reiterate  those  symptoms  here.  In  the  second  group  of  patients, 
those  who  present  what  may  be  called  the  classical  picture  of  cancer 
of  the  stomach,  there  arc  three  symptoms  which  stand  out  witli  sucli 
distinctness  as  to  be  fairly  characteristic;  these  are:  pain,  vomiting, 
and  the  presence  of  a  tumor.  But  the  pain  and  vomiting  are  not 
always  present;  and  they  vary  greatly  in  their  intensity,  not  only  in 
different  patients,  Init  in  tlie  same  ])atient  at  different  times.  Nor 
should  the  absence  of  a  tumor  be  considered  evidence  that  the  dis- 
ease is  not  cancer.  The  ])resence  of  a  tumor,  moreover,  as  already 
noted  (\).  117),  is  frc(|ucnll}'  flue  to  a  ])Ui-cl_\-  inllammalory  hyper- 


Symptoms.  279 

])lasia.  So  even  in  this  group  of  cases  where  the  clinical  picture  is 
outlined  with  reasonable  distinctness,  it  is  seen  that  diagnosis  is  no 
such  easy  matter. 

The  pain  in  cancer  of  the  stomach  differs  from  that  of  simple 
ulcer  in  several  ways.  It  is  not  so  sharp  nor  so  localized  a  pain;  it 
is  not  so  invariably  aroused  by  the  ingestion  of  food;  it  is  not  so  reg- 
ularly relieved  by  abstinence;  and  it  is  seldom  assuaged  by  a  change 
of  position  or  by  rest.  The  pain  of  cancer  of  the  stomach  is  more 
dull,  aching,  gnawing,  and  constant  than  is  that  of  ulcer;  it  is  more 
often  of  a  tearing,  shooting,  or  darting  character,  when  perigastric 
adhesions  are  dense,  or  when  neighbouring  organs  (liver,  diaphragm, 
pancreas,  etc.)  have  been  invaded  by  the  growth. 

The  vomiting  of  gastric  cancer  depends  largely  upon  the  loca- 
tion of  the  tumor.  It  usually  will  be  absent  when  the  growth  infil- 
trates the  gastric  walls  widely,  without  obstructing  the  pylorus. 
The  evidences  of  cardiac  obstruction  (see  p.  185),  attended  by  great 
pain,  hemorrhage,  and  beginning  cachexia,  are  indicative  of  carci- 
noma in  this  situation.  When  pyloric  obstruction  is  marked,  vom- 
iting becomes  frequent.  At  an  earlier  stage  any  indiscretion  in 
diet  may  set  up  an  acute  gastritis,  which,  instead  of  subsiding  as 
have  previous  similar  attacks,  will,  in  the  presence  of  cancer,  per- 
sist in  a  subacute  or  chronic  form.  This  fact  alone  is  suggestive  of 
beginning  cancer.  As  dilatation  of  the  stomach  increases,  the  vom- 
iting may  again  become  less  frequent,  but  at  the  same  time  the 
amount  of  vomited  material  will  become  more  copious,  and  the  evi- 
dences of  stagnation  and  fermentation  will  be  unmistakable.  Close 
study  of  the  vomitus,  even  in  the  early  stages,  will  often  reveal  the 
presence  of  minute  quantities  of  clotted  blood;  and  at  all  stages  of 
the  disease,  tests  for  occult  blood  as  a  rule  will  be  positive.  The 
stools  should  always  be  examined  for  occult  blood.  According  to 
Kocher,  Boas  found  this  test  positive  in  107  out  of  124  cases  of  gas- 
tric cancer.  Hamatemesis  is  rare;  there  is  seldom  so  much  blood 
lost  as  to  deserve  this  term;  or  at  least  even  if  blood  is  lost  in  quan- 
tity, it  usually  is  clotted  before  being  vomited,  and  then  presents 
the  characteristic  coffee-ground  appearance. 

Tumor  is  not  an  early  sign  in  a  pathological  sense.     It  is,  how- 


28o       Malio-nant  Diseases  of  the  Stomach  :    Carcinoma. 


to 


ever,  not  unfrequently  one  of  the  first  chnical  evidences  of  the  na- 
ture of  the  malady.  Search  for  a  tumor  should  be  systematic  and 
exhaustive.  Palpation,  with  the  patient  erect,  supine,  and  stoop- 
ing; percussion,  with  and  without  distention  of  the  stomach  or  colon, 
or  both,  with  air;  and  finally  complete  emptying  of  the  stomach — 
these  should  all  be  tried,  in  the  endeavour  to  ascertain  the  existence 
of  a  tumor.  The  tumor  moves  with  respiration,  and  if  of  the  py- 
lorus or  greater  curvature,  often  possesses  some  lateral  mobility. 
By  fixing  the  tumor  at  the  end  of  inspiration,  and  holding  it 
until  expiration  is  complete,  it  can  be  felt  to  slide  up  beneath  the 
fingers  to  its  normal  habitat  in  a  characteristic  manner.  A  tumor 
on  the  greater  curvature  becomes  more  evident  when  the  stomach 
is  distended;  one  on  the  lesser  curvature  disappears;  one  at  the 
pylorus  is  pushed  up  beneath  the  liver  if  fixed  by  adhesions,  while 
if  free  it  descends  towards  the  patient's  right.  In  the  presence  of 
ascites  it  is  of  course  necessary  to  draw  off  the  fluid  before  satisfac- 
tory palpation  is  possible. 

In  addition  to  these  three  symptoms,  there  are  three  further 
changes  constantly  present  in  gastric  cancer,  which  may  be  classed 
as  physical  signs:  these  are,  loss  oj  weight;  anccmia;  and  changes 
in  the  gastric  secretion.  Loss  of  appetite,  especially  for  meats, 
arising  without  apparent  cause,  has  already  been  mentioned  as  a 
characteristic  sign;  and  closely  following  this,  and  caused  as  Avell 
by  the  malignant  growth  itself,  occurs  progressive  loss  of  weight. 
To  render  this  apparent,  the  patient  should  be  regularly  weighed; 
it  is  not  sufficient  to  estimate  the  loss  of  weight  from  the  appearance 
of  a  man's  face,  or  his  visible  emaciation;  the  weight  should  be  re- 
corded periodically,  not  oftener  than  twice  a  week,  in  pounds  and 
ounces,  care  being  taken  to  avoid  any  errors  from  changes  in  the 
weight  of  clothing.  In  the  case  of  cancer  it  is  found  practically 
without  exception  that  the  loss  of  weight  is  progressive  and  con- 
stant, and  that  no  form  of  dieting  or  forced  feeding  will  check  the 
loss  permanently. 

The  ancEtnia  of  gastric  cancer  is  that  encountered  in  carcinoma 
elsewhere  in  the  body.  Leriche  has  recently  made  the  significant 
statement  that  if  cylindrical  gastrectomy  were  done  more  often  for 


Physical  Signs.  281 

non-stenosing  cancer,  more  cases  of  progressive  pernicious  anaemia 
would  be  cured.  (See  Regnault:  "Anemie  pernicieuse  et  cancer 
latent  de  I'estomac."  These  de  Lyon,  1905.)  In  gastric  cancer 
both  the  red  corpuscles  and  the  haemoglobin  are  reduced,  but  rarely 
to  the  extent  that  one  would  be  led  to  expect  from  the  cachexia  pres- 
ent. The  leukocyte  count  is  as  a  rule  constantly  higher  than  nor- 
mal, the  polynuclears  being  increased  at  the  expense  of  the  lympho- 
cytes. The  absence  of  hyper-leukocytosis  during  digestion  is 
considered  by  some  nearly  pathognomonic  of  cancer  of  the 
stomach. 

The  gastric  secretion  is  very  constantly  altered  in  the  later  stages 
of  carcinoma  of  this  organ.  Unfortunately  the  characteristic 
changes  are  not  early  enough  in  their  occurrence  to  be  of  material 
value  in  reaching  a  diagnosis  for  surgical  purposes.  These  changes 
are:  constant  absence  or  marked  diminution  of  the  hydrochloric 
acid,  and  the  presence  of  lactic  acid  and  other  signs  of  fermentation. 
These  changes  are  of  confirmatory  value  if  present,  but  if  not  pres- 
ent, no  import  need  be  attached  to  their  absence.  In  carcinoma  de- 
veloping on  ulcer,  hydrochloric  acid  is  apt  to  persist ;  and  the  fermen- 
tation signs  may  equally  well  be  present  in  stagnation  from  benign 
disease.  In  normal  stomachs  the  amount  of  hydrochloric  acid 
gradually  increases  after  the  ingestion  of  food;  in  cancer,  no  matter 
how  small  in  quantity  at  the  first  test  after  a  meal,  repeated  tests 
show  that  the  amount  grows  rapidly  less,  instead  of  increasing  in 
quantity  (Glutzinsky's  test).  Detection,  by  means  of  Esbach's 
reagent,  of  albumen  (nucleo-albumen  and  mucin)  in  the  washings 
from  a  fasting  stomach,  after  excluding  the  possibility  of  albumen 
being  present  from  previously  ingested  food,  speaks  in  favour  of 
carcinoma  (Salomon's  test).  The  value  of  these  tests  is  emphasized 
by  Kocher,  as  well  as  by  Zirkelbach  and  Witte. 

Diagnosis  of  carcinoma  in  its  early  stages  by  means  of  a  hcFmoIy- 
tic  blood  test,  has  been  attempted  by  Kelling,  Crile,  and  others. 
Wideroe  applied  Kelling's  test  in  50  cases,  using  hen's  blood,  ex- 
clusively: 25  of  these  patients  had  cancer,  and  25  suffered  from 
other  diseases.  He  found  that  64  per  cent,  of  the  cancer  cases  gave 
positive  results;  6  of  the  9  patients  in  whom  the  test  was  negative 


282       Malignant  Diseases  of  the  Stomach:   Carcinoma. 

T\-ere  already  cachectic,  this  fact  supporting  Kelling's  contention 
that  the  haemolysis  diminishes  with  advancing  debility.  In  the 
patients  not  having  cancer,  the  haemolysis  surpassed  30  per  cent, 
in  only  three  cases,  and  in  2  of  these  there  was  disease  of  the  blood; 
in  the  patients  with  cancer,  however,  the  degree  of  haemolysis  varied 
from  50  to  85  per  cent.  Paus,  testing  the  blood  of  90  patients,  ob- 
tained a  positive  reaction  in  65  per  cent,  of  those  in  whom  the  course 
of  the  disease  or  operation  confirmed  the  diagnosis  of  cancer.  Crile 
found  no  haemolysis  in  107  normal  individuals.  Among  50  diseased 
persons,  not  suffering  with  cancer,  the  test  was  positive  in  only  4 
(i  with  hasmoglobinuria,  i  with  eclampsia,  i  with  haematuria,  and 
I  with  undiagnosed  gastric  lesion),  while  among  50  carcinomatous 
patients  39  presented  haemolysis;  and  13  out  of  16  sarcomatous 
patients  presented  haemolysis.  In  all  patients  with  malignant 
disease  who  did  not  present  haemolysis,  the  disease  was  ad- 
vanced. 

Diagnosis. — It  may  now  be  asked:  If  the  symptoms  are  so  in- 
definite, the  physical  signs  so  misleading,  and  both  of  such  late 
developement,  how  is  a  diagnosis  to  be  reached  in  time  for  surgery 
to  be  of  any  avail ?  This  is  a  pertinent  question;  and  to  find  a  con- 
scientious answer  is  the  sorry  duty  of  the  surgeon.  It  will  not  do  to 
lay  the  onus  of  this  task  on  the  physician;  if  cancer  of  the  stomach 
is  a  surgical  disease,  the  surgeon  should  be  able  to  reach  a  reason- 
ably correct  diagnosis.  Boas  diagnosed  sixty  cases  of  gastric  cancer 
within  three  months  of  the  appearance  of  the  first  symptoms  of  the 
disease.  He  found  that  of  these  only  three  (5  per  cent.)  could  be 
treated  by  resection  of  the  growtli;  lliat  thirteen  were  suital^lc  for 
gastro-enterostomy;  and  that  two  could  only  be  explored.  Of  127 
cases  diagnosed  within  six  months  of  the  appearance  of  first  symp- 
toms. Boas  found  that  on!}'  eight  (O.3  ])er  cent.)  were  suitable  sub- 
jects for  resection.  From  this  experience  Boas  came  to  the  con- 
clusion that  the  early  diagnosis  of  gastric  cancer  is  at  present  usually 
impossible;  that  the  con.stant  moan  of  surgery  that  patients  are  not 
.sent  early  enough  for  operation,  is  not  warranted  b\-  the  facts;  and 
that  those  fjatients  who  encounter  the  question  of  o})erability  more 
than  six  months  after  the  first  onset  of  symjjtoms  afford  a  greater 


Diagnosis.  283 

hope  of  radical  cure  than  do  the  earlier  cases.  But  Hoffmann,  in 
Mikulicz's  clinique,  found  that  of  117  cases  diagnosticated  within 
three  months  of  onset,  twenty-four  (20.8  per  cent.)  could  be  treated 
by  resection;  and  of  193  cases  whose  first  symptoms  dated  back 
six  months  to  one  year,  he  found  fifty-eight  (30.3  per  cent.)  could 
be  treated  by  resection.  This  discrepancy  betw^een  the  surgical 
and  medical  statistics  is  not  due  to  the  fact  that  Mikulicz  allowed 
wider  limits  to  the  indications  for  radical  operation ;  but  because  the 
worst  cases  go  to  the  physician  and  the  more  operable  ones  go 
directly  to  the  surgeon.  Moreover,  the  patients  seen  by  medical 
men  are  either  hospital  out-patients,  or  those  in  private  practice — 
the  number  is  great,  but  the  patients  do  not  remain  long  under  ob- 
servation; they  pass  on  to  another  clinique. 

It  has  been  true  in  the  past,  but  it  is  now^  much  less  true,  at  least 
of  progressive  physicians,  that  they  did  not  send  the  patients  early 
enough  to  the  surgeon.  The  surgeon  should  be  called  in  consulta- 
tion as  soon  as  an  anatomical  cause  for  the  gastric  disease  is  recog- 
nized, and  in  obscure  cases  he  should  be  consulted  even  before  this 
stage  of  accuracy  in  diagnosis  has  been  reached.  Likewise,  when 
gastric  cases  come  directly  to  the  surgeon,  he  is  only  too  glad  to  have 
the  opinion  of-  his  medical  colleagues,  and  to  avail  himself  of  such 
aids  as  the  clinical  laboratory  can  afford.  But  he  has  been  the  first 
to  recognize  that,  as  all  signs  fail  in  dry  weather,  so  the  possibility 
of  reaching  an  accurate  diagnosis  must  be  postponed  in  certain  in- 
stances until  the  patient  will  be  beyond  the  help  of  surgery.  Under 
such  circumstances,  and  when  there  is  undoubtedly  some  actual 
anatomical  lesion  of  the  stomach,  even  though  an  exact  patholog- 
ical diagnosis  of  the  lesion  has  not  been  reached,  but  because  it  is 
evident  that  only  some  forni  of  surgical  operation  will  be  of  any 
avail  in  curing  the  disease, — under  these  circumstances,  we  repeat, 
we  believe  exploratory  operations  should  be  undertaken.  We  do 
not  advocate  exploration  as  a  therapeutic  test;  we  do  not  say,  do 
gastro-enterostomy  for  pain  in  the  stomach  and  if  the  result  is 
favourable  conclude  that  the  disease  was  gastric  ulcer,  and  if  the  pa- 
tient dies  assert  that  death  was  clearly  due  to  the  cancerous  ca- 
chexia; nor  do  we  counsel  exploration  merely  because  it  is  easier  for 


284       Malignant  Diseases  of  the  Stomach:   Carcinoma. 

the  surgeon  and  possibly  less  distasteful  to  the  patient  than  careful 
examination  and  repeated  study  of  the  disease  by  other  means;  and 
we  do  believe  that  in  the  vast  majority  of  patients  with  gastric  dis- 
orders a  diagnosis  of  sufficient  accuracy  can  be  reached  before  oper- 
ation is  undertaken  thoroughly  to  justify  the  operation  when  done. 
We  are  convinced,  moreover,  that  if  chronic  and  rebellious  cases 
of  indigestion  were  more  promptly  turned  over  to  the  surgeon,  and 
if  suitable  operations  were  done  on  such  patients,  there  would  be 
fewer  cases  of  carcinoma  of  the  stomach  observed  by  physicians. 
It  seems  to  us  that  every  case  diagnosticated  certainly  as  carcinoma 
of  the  stomach  before  operation  is  a  disgrace  to  the  attending  phy- 
sician, provided  he  has  had  the  patient  under  treatment  for  more 
than  a  few  weeks.  In  that  space  of  time  it  is  at  present  usually 
impossible  to  render  absolute  the  diagnosis  of  a  gastric  carcinoma 
while  still  in  the  operable  stage;  but  it  is  entirely  possible,  and  we 
contend  with  all  earnestness  that  it  should  be  done,  to  reach  within 
that  time  the  conclusion  that  an  anatomical  basis  for  the  symp- 
toms exists,  and  that  this  can  be  removed  only  by  operative 
means. 

In  recapitulation,  then,  it  may  be  said  that  the  presence  of  can- 
cer should  be  suspected  when  chronic  gastric  catarrh  exists  without 
any  discoverable  cause  (such  as  abuse  of  food,  of  alcohol,  of  drugs; 
circulatory  disturbances  of  the  heart  or  liver;  or  diseases,  such  as 
gall  stones,  gastric  ulcer,  etc.,  which  would  cause  some  definite 
lesions  in  the  region  of  the  stomach), especially  if  this  chronic  gas- 
tritis be  in  a  patient  over  forty  years  of  age,  and  if  it  be  attended 
bylo.ssofap])clitc  for  meals  (Kocher).  If  a  tumor  exists,  the  diagnosis 
is  less  difficult;  but  the  tumor  must  l)e  distinguished  from  a  dis- 
tended gall  bladder,  from  a  growth  of  the  colon,  of  the  pancreas, 
etc.  In  obscure  cases  distension  of  the  stomacli  with  air  should 
never  be  neglected;  this  may  render  a  hidden  tumor  palpable,  and 
the  characteristic  pyramidal  shape  of  a  j^yloric  growth  (apex  toward 
the  duodenum  and  indistinct  base  toward  the  body  of  the  stomach) 
can  frequently  Ijc  rerogni/ed  (Kocher).  Occult  blood  in  the 
stomach  contents  and  f;eces  is  the  most  valuable  of  the  laboratory 
findings.     In  non -malignant   ulcerations  of  the  stomach,  rest  in 


Diagnosis.  285 

bed  with  milk  diet  will  cause  the  disappearance  of  occult  blood. 
In  cancer  no  treatment  has  any  effect. 

In  cases  where  the  stomach  affection  resists  medical  treatment, 
exploratory  operation  is  indicated.  This  is  not  always  satisfactory, 
nor  is  it  always  possible,  even  by  the  senses  of  touch  and  sight,  to 
make  a  positive  diagnosis  of  carcinoma.  Fortunately,  the  benefit  is 
generally  given  to  the  patient  and  the  diseased  portion  of  the  stomach 
removed  when  practicable,  on  the  supposition  that  malignancy  is 
present.  Many  of  the  most  experienced  operators  have  been  mis- 
led by  the  conditions  present,  the  true  condition  of  affairs  not  being 
realized  until  the  removed  part  of  the  stomach  was  subjected 
to  microscopical  examination.  If  a  distinct  tumor  is  present,  it 
can  generally  be  recognized  as  carcinomatous  by  its  irregular  shape; 
by  its  "knotty"  feel;  by  diffused  induration  into  the  surrounding 
structures.  Before  there  is  tumor  formation  of  any  moment,  it  is 
practically  impossible  to  differentiate  between  the  thickening  and 
induration  consequent  upon  inflammation  and  that  due  to  malig- 
nancy. While  it  is  true  that  the  mortality  following  posterior  gas- 
tro-jejunostomy  in  benign  disease  is  lower  than  that  following  gas- 
trectomy, it  is  always  justifiable  and,  in  the  opinion  of  some  sur- 
geons, mandatory,  to  subject  the  patient  to  the  latter  risk  rather  than 
to  the  surely  fatal  results  of  an  undisturbed  malignant  condition, 
if  such  be  present.  If  there  were  involvement  of  the  lymph  glands 
with  metastasis  to  any  of  the  neighbouring  viscera,  the  diagnosis  of 
malignancy  would  be  unquestioned;  without  these  complications 
or  extensions,  in  the  absence  of  the  more  or  less  characteristic  tumor 
formation,  the  diagnosis  must  be  tentative  until  a  final  appeal  can  be 
made  either  to  the  microscope,  if  the  affected  portion  of  the  stomach 
be  removed,  or  to  the  extension  of  the  disease  if  it  be  allowed  to 
remain  in  situ.  Even  a  microscopical  diagnosis  is  occasionally  in 
error.  If  the  freezing  microtome  is  used  to  facilitate  diagnosis 
during  an  operation,  the  surgeon's  duty  of  course  is  to  do  a  radical 
operation,  when  possible,  if  the  report  from  the  pathologist  is  posi- 
tive; but  if  negative,  he  must  rely  solely  on  the  clinical  diagnosis. 

Prognosis. — Though  medical  means  are  powerless  to  cure  can- 
cer in  any  region  of  the  body,  yet  no  one  would  be  so  foolish  as  to 


286       Malignant  Diseases  of  the  Stomach:   Carcinoma. 

deny  that  in  cases  of  inoperable  tumors  much  may  be  accomphshed 
to  prolong  life  and  to  mitigate  suffering.  Tyson  says  he  is  quite  sure 
that  a  great  deal  more  can  be  done  in  this  way  than  is  commonly 
thought  possible.  The  wide  experience  of  Jacobi,  so  cautiously 
and  conservatively  expressed,  in  regard  to  the  beneficial  effect  of 
methylene  blue  (methylthionin  hydrochloride)  in  such  patients,  is 
a  gratifying  example  of  what  may  be  done  by  medical  science  even 
for  hopeless  cases.  But,  as  Bland  Sutton  said  a  number  of  years 
ago,  as  long  as  we  are  ignorant  of  the  cause  of  cancer,  so  long  must 
the  only  successful  treatment  be  the  extirpation  of  the  growth. 

It  is  sometimes  questioned  by  physicians  whether  surgery  can 
really  accomplish  more  in  prolonging  life  than  can  medical  measures. 
It  is  sometimes  doubted  whether  surgery  can  ever  effect  a  cure.  To 
answer  these  questions  surgeons  must  show  the  ultimate  results  of 
their  operations.  They  must  trace  their  patients  for  a  period  of  at 
least  three  years  after  operation,  and  report  their  actual  condition  at 
the  end  of  that  time.  But  before  the  duration  of  life  and  the  prospect 
of  ultimate  cure  after  surgical  operation  are  discussed,  and  even  before 
a  comparison  is  made  with  the  expectation  of  life  and  the  certainty  of 
ultimate  death  from  the  disease  which  are  necessary  attendants  upon 
purely  medical  treatment;  before  these  interesting  questions  are  dis- 
cussed, we  repeat,  it  is  expedient  to  study  the  immediate  dangers  of 
the  operations  which  surgeons  are  urging  in  the  treatment  of  this 
disease. 

The  mortality  and  the  ultimate  results  of  operations  for  benign 
gastric  disease  have  already  been  considered  in  detail  (pp.  105,  108). 
The  results  of  such  operations,  which  may  be  considered  in  the  light 
of  preventative  operations  for  cancer,  should  be  compared  with  the 
following  figures  of  operations  undertaken  for  the  cure  of  this  disease. 

PARTIAL  GASTRECTOMY  FOR  CARCINOMA. 

Mortality 
Operator  and  Rfference.  Cases.  Deaths.  per  cent. 

Berg  (cited  in  Jour.  Amer.  Med.  Assoc,   1907, 

ii,  2048) 62  9  14.5 

Braun   (Creite:    Deutsch.   Zcil.   f.    Chir.,    1007, 

Lxx-w-ii,  275) 50  19  38.0 

Crile  (Ohio  State  Med.  Jour.,  1908,  iv,  80) 40  (20)  7  (o)  17.5 

Czerny   (Kausch:      Berl.    kiin.     Woch.,    1907, 

xliv,  509,  574) 62  19  30.0 


Prognosis.  287 

Partial  Gastrectomy  for  Carcinoma. — {Continued). 

Mortality 
Operator  and  Reference.  Cases.  Deaths.  per  cent. 

Deaver  (Records  of  German  Hospital,  Phila.) 14  (  9)  3(0)  21.42 

Garre   (Matti:     Deutsch.    Zeit.    f.    Chin,    1905, 

Ixxvii,  99) 26  7  26.9 

GouUioud   (Faysse:    Arch.   Internat.   de     Chir. 

Gastro-Intest.,  1908,  ii,  28) 13  i  7.7 

Hahn    (Matti:    Deutsch.    Zeit.    f.    Chir.,    1905, 

Ixxvii,  99) _ ...28  10  35.7 

Hartmann     (Matti:     Deutsch.    Zeit.    f.    Chir., 

1905,  Ixxvii,  99) 22  7  31.8 

Kocher     (Corresp.-Bl.     f.     Schweizer      Aerzte, 

1907,  xxxvii,  265) 122(25)  ,30(4)  24.5 

Kronlein     (Matti:      Deutsch.     Zeit.     f      Chir., 

1905,  l.xxvii,  99) 50  14  28.0 

Maydl  (Paterson:  Gastric  Surgery,  New  York, 

1906,  p.  104) 25  4  16.0 

Mayo    (N.  Y.    State   Jour,    of   Med.,    1906,  vi, 

63) 81(25)  12(1)  14.15 

Meyer   (N.  Y.    State   Jour,    of   Med.,    1906,  vi, 

68) 5  I  20.0 

Kappeler  (Matti:   Deutsch.  Zeit.  f.  Chir.,  1905, 

Ixxvii,  99) 30  8  26.6 

Mikulicz  (Matti:   Deutsch.  Zeit.  f.  Chir.,  1905, 

Ixxvii,  99) 100  37  37-0 

Monprofit    (Arch.    Prov.    de    Chir.,    1906,    xv, 

26) 30(15)  6(0)  20.0 

Moynihan   (Trans.    Clin.   Soc.    London,    1906, 

xxxix,  84) 7  I  14.28 

Paterson   (Gastric   Surgery,   New  York,    1906, 

P-  104) 4  I  25.0 

Poppert    (Riese:    Deutsch.   med.  Woch.,    1908, 

xxxiv,  735) 32  6  18.8 

Riese    (Deutsche,    med.    Woch.,    1908,     xxxiv, 

735) 24  7  29.1 

Robson,    Mayo    (Kausch:     Berl.    khn.    Woch., 

1907,  xliv,  509;  574) ..  16.0. 

Roux     (Matti:     Deutsch.    Zeit.   f.    Chir.,    1905, 

Ixxvii,  99) 39  13  33.33 

Schoenborn  (Riese:  Deutsch.  med.  Woch.,  1908, 

xxxiv,  735) 32  ,9  28.0 

Vassalo  (Semana  Medica,  1906,  xiii,  407) 17  i  5.88 

Taking,  then,  the  more  favourable  recent  figures  of  Kocher  (16  per 
cent.),  of  Mayo  (4  per  cent.),  and  of  Monprofit  (no  deaths  in  the  last 
15  operations),  which  offset  to  a  certain  extent  the  rather  ancient  sta- 
tistics of  Mikulicz  (1901),  Hahn  (1898),  Kronlein,  Roux,  Hartmann, 
and  others,  we  have  a  total  of  747  partial  gastrectomies,  with  189 
deaths,  or  a  mortality  of  over  25  per  cent.,  as  the  immediate  result  of 
operations  for  the  radical  cure  of  gastric  carcinoma.  This,  it  will  be 
remembered,  is  to  be  contrasted  with  an  immediate  mortality  of  about 
5  per  cent,  after  operations  for  the  prevention  of  this  disease. 


Malignant  Diseases  of  the  Stomach:   Carcinoma. 


•fc> 


It  will  next  be  proper  to  determine  what  proportion  of  the  three- 
fourths  of  patients  who  survive  gastrectomy  may  reasonably  hope  to 
be  ultimately  and  permanently  cured  of  their  disease.  Let  it  not  be 
forgotten  that  over  80  per  cent,  of  patients  surviving  the  prophylactic 
operation  have  been  proved  to  be  ultimately  cured.  Robson  and 
]Movnihan  in  1904  studied  the  statistics  bearing  on  this  point  from  the 
cliniques  of  Kronlein  and  Mikulicz;  Kausch  has  more  recently  (1907) 
tabulated  the  results  of  Czerny  and  Kocher.  From  all  these  sources  it 
is  evident  that  patients  suffering  with  gastric  carcinoma  have,  under 
medical  treatment,  an  expectation  of  life  of  about  twelve  months  from 
the  beginning  of  the  disease.  Many  writers  put  it  at  less.  Not  only  is 
this  the  duration  of  life,  but  it  should  not  be  forgotten  that  at  the  end  of 
that  time  the  patients  under  medical  treatment  will  all  he  dead.  There 
will  not  be  even  one  among  those  treated  medically  who  at  the  conclu- 
sion of  that  period  will  have  had  up  to  that  time  no  recurrence 
of  a  mahgnant  tumor  successfully  removed  by  operation,  and 
who  may,  therefore,  still  be  considered  as  curable — as  potentially 
cured.  If,  then,  surgery  can  show  any  permanent  cures,  and  if 
the  average  duration  of  life  under  surgical  treatment  is  longer, 
or  at  least  not  less  than  that  under  medical  treatment,  the  con- 
clusion surely  is  justified  that  surgical  intervention  is  best  for  these 
patients.  The  question,  in  fact,  is  not  "Is  operation  a  sure  cure 
for  gastric  cancer?"  but  "Does  anything  else  offer  even  the  shadow 
of  a  chance  ?"  Even  if  the  surgeon  is  aware  that  one  out  of  four  pa- 
tients, or  four  out  of  sixteen  patients,  on  whom  he  operates  for  gastric 
cancer  will  surely  die,  he  should  not  therefore  hold  his  hand,  and 
thereby  condemn  the  whole  series  to  certain  death  in  about  a  twelve- 
month's time.  If  he  could  say  with  certainty  to  himself,  "I  have  had 
three  recoveries  from  gastrectomy;  this  is  my  fourth  patient,  and  he  is 
therefore  sure  to  die  from  the  operation" — under  such  circumstances, 
of  course,  no  surgeon  would  be  justified  in  operating.  But  this  is  not 
the  way  to  argue  from  .statistics;  for  this  surgeon  with  equal  justice 
might  have  .said  to  himself  in  the  beginning,  "This  is  my  fir.st  patient 
for  gastrectomy;  even  though  the  three  following  ])aticnts  should  re- 
cover, this  first  one  will  surely  die;  I  will  therefore  refuse  to  operate 
for  fear  of  killing  him."     Statistics  are  a  valuable  guide  to  prognosis 


rrognosis.  209 

for  those  who  know  how  to  use  them;  and  no  surgeon  can  justifiably 
undertake  an  operation  which  he  is  convinced  will  kill  his  patient;  but 
by  employing  that  most  precious  quality  of  mind  known  as  judge- 
ment, and  by  selecting  the  patients  who  are  suited  for  the  operation  in 
question,  the  skillful  surgeon  is  enabled  to  save  many  lives  other- 
wise doomed  to  destruction. 

What,  then,  is  the  prognosis  in  regard  to  prolongation  of  life  by 
operation  ?  Moynihan  studied  the  average  duration  of  life  in  patients 
who  underwent  gastrectomy  in  the  cliniques  of  Kronlein  and  Mikulicz ; 
he  found  that  from  the  beginning  to  the  end  of  the  disease  it  was  as 
much  as  twenty-four  to  twenty-five  months,  or  more  than  twice  as 
long  as  the  average  duration  of  life  without  operation.  Paterson's 
figures  from  collective  statistics  give  the  duration  of  life  after  operation 
(86  operations  in  all)  as  an  average  of  nineteen  months  after  total  gas- 
trectomy (17  patients),  of  twenty-two  and  a  half  months  after  subtotal 
gastrectomy  (14  patients),  and  of  just  over  two  years  after  partial  gas- 
trectomy (55  patients).  Kausch  reported  an  average  duration  of  life 
after  operation  of  18.3  months  in  Mikulicz's  patients,  of  18.7  months 
in  Kocher's  patients,  and  of  18  months  in  Kronlein's  patients.  It 
should  be  noted  that  Moynihan's  figures  refer  to  duration  of  life  after 
the  appearance  of  symptoms  of  gastric  cancer,  w^hile  Paterson's  and 
Kausch's  refer  only  to  the  duration  of  life  after  operation.  With  this 
allow^ance,  it  is  seen  that  the  figures  agree  very  closely;  and  as  they  are 
gathered  from  very  different  sources  (Moynihan's  and  Kausch's  from 
the  German  cliniques,  and  Paterson's  largely  from  British  sources), 
each  series  serves  to  confirm  the  other.  Now  if  these  patients  had  not 
been  operated  on,  the  duration  of  life  from  the  beginning  oj  the  disease 
(not  from  the  date  of  operation)  would  have  been  at  most  one  year, 
probably  less.  Thus,  as  we  have  elsewhere  pointed  out,  not  only  is 
life  considerably  prolonged,  but  at  the  end  of  this  period  a  number  of 
patients  are  still  living  and  in  good  health ;  whereas  if  no  operation  had 
been  done,  they  would  all  of  them  have  been  dead  before  this  time 
was  reached. 

Moreover,  not  only  may  the  mere  addition  to  the  patient's  Hfe  be 
of  utmost  importance  from  a  social,  commercial,  or  financial  point  of 
view,  but  death,  when  it  does  come,  will  attack  the  sufferer  in  a  less 
19 


290       Malignant  Diseases  of  the  Stomach:    Carcinoma. 

hideous  form.  The  patient  will  not  die  of  starvation,  as  he  would  have 
done  had  no  operation  been  perfornied.  And  although  it  would  be 
heartless  in  the  surgeon  to  teh  his  patient,  when  urging  operation,  that 
although  .the  chance  of  permanent  cure  is  slight,  it  is  nevertheless 
altogether  likely  that  he  will  die  of  cancer  of  the  Kver,  with  its  attend- 
ant cachexia,  and  not  from  progressive  starvation — although,  we  re- 
peat, to  draw  such  a  picture  of  the  future  for  his  unfortunate  patient 
would  be  diabohcally  cold-blooded  in  the  surgeon,  yet  we  doubt  not 
that  many  a  patient,  dying  of  the  cancerous  cachexia  some  two  years 
after  the  operation,  will  daily  bless  the  art  of  surgery  which  has  so  pro- 
longed his  life  and  mitigated  his  suffering  during  the  gradual  approach 
of  death. 

But,  though  the  chances  of  permanent  cure  are  slight,  they  are  not 
altogether  imaginary.  Leriche  quotes  the  reckoning  of  Petersen  and 
Colmers  that  one-fifth  of  those  who  survive  the  resection  will  be  per- 
manently cured.  According  to  Kausch,  Makkas  traced  92  of  Miku- 
licz's patients  who  had  been  operated  on  before  1902.  He  found  27 
of  these  (30  per  cent,  of  those  operated  on)  still  in  good  health;  of 
these  17  were  well  more  than  3  years  after  operation — which  number 
represented  14.3  per  cent,  of  the  whole  number  operated  on,  and  23.9 
per  cent,  of  those  who  recovered  after  operation.  Petersen  and  Col- 
mers traced  18  patients  from  Czerny's  clinique,  and  found  that  6  were 
alive  and  well  three  years  or  more  after  operation — being  20  per  cent. 
of  the  whole  number  operated  on,  and  t,t,  per  cent,  of  those  who  sur- 
vived operation.  Of  31  patients  who  recovered  after  gastrectomy  in 
Braun's  clinique  21  died  of  recurrence  soon  after;  3  patients  lived 
respectively  20  months,  55  months,  and  22  months  after  operation, 
and  died  of  intercurrent  disease,  without  recurrence;  one  patient 
was  well  more  than  14  years  after  the  operation;  one  was  alive 
with  recurrence  one  year  after  the  operation;  and  the  remaining 
5  patients  had  been  operated  on  too  recently  to  be  counted.  In 
other  words,  of  26  patients  from  Hraun's  clinique  that  arc  available 
for  estimating  the  ultimate  results  of  gastrectomy,  two  patients  cer- 
tainly, and  possibly  four  (15.4  per  cent,  of  those  who  survived),  can  be 
counted  as  having  been  ultimately  cured. 


Prognosis. 


291 


END  RESULTS  OF  GASTRECTOMY  FOR  CARCINOMA. 


Cases  withodt  Recurrence  after  Three 


Operator. 


No.  of 
Patients. 


Braun  (cited  by  Creite) 2 

British  Surgeons  (cited  by  Paterson) 7,7, 

Czerny  (cited  by  Kausch) 6 

Kocher   (Corr.-Bl.  f.  Schw.  Aerzte,   1907,  xxxvii, 

265). ._. 18 

Kronlein  (cited  by  Kausch) 2 

Mikulicz  (cited  by  Kausch) 17 

Robson  (cited  by  Kausch) 


Years. 

Per  Cent,  of 

Whole  No.  of 

Operations 


19-3 
7.0 

14-3 
14.0 


Per  Cent,  of 

Those  Who 

Survived 

Operation. 

6.5 
38.3 
33-0 

26.0 
10. o 
24.0 


In  1906  Paterson  collected,  mainly  from  British  sources,  the  end 
results  of  79  cases  of  gastrectomy  (seven  others,  w^ho  also  recovered, 
could  not  be  traced);  46  patients  (58.4  per  cent,  of  those  traced)  dying 
of  recurrence  within  three  years,  and  33  patients  (41.6  per  cent,  of 
those  traced)  being  alive  and  well  at  the  end  of  three  years  or  more 
after  the  operation.  No  less  than  12  patients  (15  per  cent,  of  those 
traced)  were  in  perfect  health  more  than  five  years  after  the  opera- 
tion, some  being  in  good  health  at  periods  varying  from  six  to  fourteen 
years  after  operation. 

PATERSON'S   STATISTICS    OF   END    RESULTS    OF    GASTRECTOMY. 

Still  Living  and  Well: 


Nature  of 

Operation.  Recovered.  Traced. 

Total  gastrectomy 17  14 

Subtotal  gastrectomy 14  12 

Partial  gastrectomy 55  53 


Died  Since 
Operation. 

5 
6 

35 


Three  Years 

After 
Operation. 

6 

3 
12 


Five  Years 

After 
Operation. 


21 


3 
3 
6 

12 


Total 86  79  46 

Well  three  years  after  operation,  33,  or  38.3  per  cent,  of  recoveries. 
Well  five  years  after  operation,  12,  or  14  per  cent,  of  recoveries. 

Leriche  still  more  recently  has  collected  records  of  94  patients 
treated  by  gastrectomy,  who  were  traced  and  found  in  good  health 
three  or  more  years  after  operation;  of  these  no  less  than  34  had  been 
traced  for  from  five  to  ten  years  after  operation,  and  6  for  more  than 
ten  years.  Kocher  (1907)  reports  10  of  his  patients  (about  9  per  cent, 
of  those  operated  on)  in  good  health  more  than  four  years  after  oper- 
ation. Of  Robson's  patients,  14  per  cent,  were  without  evidence  of 
gastric  disease  four  years  after  operation.     Of  130  gastrectomies  done 


292 


Malignant  Diseases  ot  the  Stomach 


C 


arcinoma. 


bv  ^Mikulicz  and  his  associates,  which  were  analyzed  by  Makkas,  a 
radical  cure  was  reckoned  in  18.4  per  cent.;  only  5  patients  who  sur- 
vived the  three  year  limit  died  later  of  recurrence.  Among  the  94 
cases  traced  more  than  three  years  by  Leriche,  only  5  had  recurrences 
after  this  space  of  time,  and  only  two  of  these  recurrences  were  after 
the  five  year  limit.  Though  recurrence  is  thus  seen  to  be  rare  after 
the  three  year  limit  it  is  extremely  unusual  after  four  years,  and 
nearly  unkno^^Mi  when  five  years  have  elapsed. 

Possiblv  still  further  statistics  might  be  quoted;  but  those  already 
given  are  sufficient  to  show  that  ice  may  expect,  at  present,  about  10 
or  15  per  cent.  0}  patients  treated  by  gastrectomy  to  be  permanently  cured 
without  liability  of  recurrence. 

There  is  still  another  question  of  interest  in  regard  to  prognosis. 
That  is  the  ratio  of  operable  cases  to  the  whole  number  of  patients 
seen.  The  following  table,  compiled  from  Kausch  (1907),  Creite 
(1907),  and  Moynihan  (1906),  gives  the  total  number  of  cases  under 
observation;  the  total  number  of  operations,  with  the  relation  of 
these  to  the  whole  number  of  patients;  and  the  number  of  radical 
operations  done,  with  the  relation  of  these  to  the  whole  number  of 
patients. 

RATIO   OF  OPERABLE  CASES  TO  WHOLE  NUMBER  OF  PATIENTS. 


Author. 

Total  Cases. 

Whole  No.  of 
Ops.  Includ- 
ing Explora- 
tions. 

Ratio  to 

Whole  No.  of 

Patients. 

No.  OF 

Resec- 
tions. 

Ratio  to 

Whole  No.  of 

Patients. 

Per  Cent. 

Per  Cent. 

Boas 

234 

48 

20.5 

II 

4-7 

Braun 

241 

211 

/    87.5 

50 

/  20.7 

(of  whom  30  refused 

\  lOO.O 

\23.7 

op.)  =  211. 

Kbrte 

126 

115 

91.0 

38 

30.0 

Kronlein . . . 

264 

197 

7S-0 

SO 

19.0 

Mikulicz. . . 

665 

458 

/69.0 

164 

/24-7 

(of  whom  59  refused 

\7S-o 

\27.0 

op.)  =  606. 

Moynihan.. 

70 

59 

84-3 

10 

14-3 

What  shall  the  surgeon  do  with  iho.sc  patients  in  whom  the  disease 
is  so  far  advanced  as  to  forbid  a  radical  operation  ?  In  other  words, 
Do  palliative  operations  prolong  life  and  adrl  lo  the  ])atient's  com- 


Prognosis.  293 

fort  ?  Until  operation  is  more  frequently  undertaken  in  the  very 
early  stages  of  the  malady,  gastro-jejunostomy  must  still  be  the  opera- 
tion most  often  adopted.  It  has  been  rare  in  our  experience,  as  we 
think  also  in  that  of  other  surgeons,  for  a  patient  in  whom  cancer  has 
been  certainly  diagnosticated  before  operation  to  present  conditions 
admitting  of  gastrectomy.  The  operations  of  gastrectomy  in  our 
own  hands  have  been  on  patients  in  whom  the  existence  of  malignant 
disease  was  merely  suspected,  but  not  certainly  known,  before  the  ab- 
domen was  opened.  A  palpable  tumor  felt  before  operation  will 
naturally  suggest  cancer;  but  the  case  reports  already  referred  to 
(see  p.  117),  in  which  such  masses  have  been  known  to  disappear 
after  gastro-enterostomy,  prove  that  all  palpable  tumors  are  not  car- 
cinomatous in  nature.  As  Dr.  Deaver  has  urged  elsewhere,  it  is  in 
this  class  of  patients  that  exploratory  laparotomy  finds  its  most  legit- 
imate field.  The  statistics  from  the  cliniques  of  Kronlein  and  Miku- 
licz, studied  at  length  by  Moynihan,  show  that  patients  who  had  under- 
gone an  exploratory  laparotomy  in  which  no  further  operative  treat- 
ment was  possible,  actually  lived  longer  than  did  those  whose  disease 
was  so  far  advanced  as  to  make  even  an  exploration  unjustifiable, 
or  those  who  entirely  refused  an  operation  of  any  kind.  In  very  many 
operations,  moreover,  which  are  commenced  as  explorations  merely, 
it  is  found  possible  either  to  remove  the  growth,  or  at  least  to  perform 
a  palliative  operation  which  will  materially  prolong  life  and  relieve 
suffering.  This,  after  all,  and  not  the  production  of  statistics,  is  the 
end  and  object  of  surgery. 

Gastro-jejunostomy  for  carcinoma  is  naturally  attended  by  a  larger 
mortality  than  are  similar  operations  for  benign  disease.  The  re- 
ported figures  may  be  seen  in  the  annexed  table. 

GASTRO-JEJUNOSTOMY  FOR  CARCINOMA. 

Mortality 
Author  and  Reference.  Cases.  Deaths.  Per  cent. 

Berg .---103  22  21.3 

Deaver 31  10  32.25 

Krause 36  12  ^;^ 

Kronlein 74  18  24.3 

Mikulicz 143  48  33.3 

Monprofit iig  52  43.7 

Moynihan 35  5  ■  14.7 


Paterson. 


7  I  14-3 


Schloffer 66(29)  14(2)  21        (7) 


294       Malignant  Diseases  of  the  Stomach:   Carcinoma. 

The  average  duration  of  life  after  gastro-jejunostomy  is  almost 
certainly  longer  than  when  no  operation  has  been  done;  but  so  far 
as  we  have  been  able  to  ascertain,  the  details  thus  far  have  been  pub- 
lished in  too  few  cases  for  very  positive  conclusions  to  be  drawn. 
Moynihan  traced  26  out  of  30  patients  who  recovered  after  gastro- 
jejunostomy for  cancer;  six  patients  were  still  alive,  one  after  thirteen 
months,  and  five  less  than  twelve  months  since  the  operation.  Of 
the  20  patients  who  had  died,  the  shortest  duration  of  life  after  opera- 
tion was  fourteen  weeks;  while  two  patients  had  lived  more  than  two 
years.  In  Kronlein's  patients  who  recovered  from  gastro-jejunostomy 
and  were  traced  (54  in  number),  the  average  duration  of  life  after 
operation  was  193  days  (over  six  months),  and  in  Mikulicz's  patients 
it  was  6.4  months — or  in  each  series  about  3  months  longer  than  if 
no  operation  had  been  employed.  Moynihan,  however,  notes  that 
if  in  this  reckoning  the  immediately  fatal  cases  are  included,  the 
average  duration  of  life  is  slightly  less  than  if  no  operation  had  been 
employed.  However,  the  statistics  of  Mikulicz  were  compiled  in 
1901,  and  those  of  Kronlein  in  1902;  and  it  is  but  reasonable  to  sup- 
pose that  since  that  time  the  results  of  gastro-jejunostomy  for  carci- 
noma have  kept  pace  with  the  improvement  in  other  departments 
of  gastric  surgery. 

It  appears  from  these  statistics  that  in  the  hands  of  experienced 
abdominal  surgeons  the  immediate  mortality  from  gastro-jejunostomy 
in  patients  with  cancer  of  the  stomach  is  as  high  as,  and  in  some  in- 
stances even  higher  than  that  of  partial  gastrectomy  for  the  same 
disease.  But  e\'cn  if  these  statistics  represent  correctly  tlic  practice 
of  the  present,  which  is  a  httlc  doubtful,  it  is  not  i)robal)le  that  this 
difference  in  the  mortality  of  gastrectomy  and  gastro-jejunostomy  for 
cancer  is  due  to  any  inherent  qualities  of  tlie  respective  operations;  it 
seems  rather  attributable  to  the  fact  that  gastro-jejunostomy  has  been 
and  is  still  employed  in  patients  already  nearly  dead  from  starvation 
and  cachexia,  with  the  forlorn  hope  of  relieving  their  discomfort  during 
their  remaining  da}'s  on  earth.  On  the  oilier  hand,  surgeons  have 
been  fearful  of  employing  so  extensive  an  operation  as  even  partial 
gastrectomy  in  any  but  carefully  selected  patients.  We  believe  that, 
other  things  being  equal,  gastrectomy  is  the  more  serious  operation 


rrognosis.  295 

of  the  two;  and  were  it  to  be  used  as  indiscriminately  as  gastro-jejun- 
ostomy  has  been,  the  relative  mortality  rates  would  appear  in  true 
proportion.  Oversight  of  this  fact  seems  to  give  some  basis  for  the 
enthusiasm  with  which  Robson  and  Moynihan  suggest  the  employ- 
ment of  gastrectomy  as  a  palliative  operation  even  in  cases  where  it 
is  manifestly  impossible  to  remove  the  entire  disease.  They  speak 
as  follows  of  the  results  of  gastro-jejunostomy  in  cases  of  pyloric  ob- 
struction from  cancer:  "There  can  be  no  doubt  that  in  such  cases 
gastro-enterostomy  is  productive  of  the  most  remarkable'  benefit  to 
the  health  and  well-being  of  the  patient.  The  weight  increases,  the 
appetite  and  the  power  of  gratifying  it  return,  and  vomiting,  often 
the  most  distressing  and  unceasing  symptom,  stops  at  once.  But 
there  can  also  be  no  doubt  that  in  some  instances,  when  the  growth 
does  not  actually  obstruct  by  its  bulk  the  onward  passage  of  food, 
a  decided  benefit  results  from  the  operation."  But  they  say  later, 
''The  question  may  arise  as  to  whether  gastrectomy  should  not  be  per- 
formed deliberately  as  a  palliative  operation  in  cases  where  an  early 
secondary  deposit  can  be  seen  in  the  liver,  or  inaccessible  or  irremov- 
able glands  be  found  in  the  pancreas,  or  along  the  aorta  and  vena 
cava.  If  we  take  into  account  the  following  advantages  of  gastrec- 
tomy as  compared  with  gastro-enterostomy — that  in  the  most  compe- 
tent hands  its  mortahty  is  not  greater,  but  is  even  less,  than  the  mor- 
tality of  gastro-enterostomy;  that  a  prolongation  of  hfe  for  ten  months 
longer  than  the  period  given  by  gastro-enterostomy  is  the  rule;  that 
the  comfort,  the  general  health,  appetite,  and  well-being  6i  the  patient 
are  all  emphatically  better;  and,  finally,  that  the  patient  has  always 
a  chance,  even  though  it  is  of  the  slenderest,  of  a  complete  recovery 
from  his  disease — if  we  take  all  these  into  our  consideration,  there 
can  be  no  doubt  that  the  operation  of  choice  will  alw^ays  be  gas- 
trectomy." In  spite  of  this  partiality  of  these  experienced  surgeons, 
it  seems  to  us  that  gastrectomy  is  best  reserved  for  those  cases  in 
which  it  seems  likely  that  it  will  be  a  curative  operation.  Surely 
if  employed  when  secondary  deposits  exist  in  the  liver,  or  where  there 
are  inaccessible  or  irremovable,  but  nevertheless  surely  carcinoma- 
tous lymph  nodes, — surely  in  such  cases  there  can  be  not  even  the 


296       Malignant  Diseases  of  the  Stomach:    Carcinoma. 

slenderest  chance  of  a  complete  recovery  from  the  disease  after  gas- 
trectomy. 

Finally,  it  is  of  interest  in  this  connection  to  recall  the  researches 
of  Katzenstein,  as  the  result  of  which  he  suggested  that  the  arrest  of 
carcinomatous  growths  sometimes  observed  after  gastro-jejunostomy 
might  be  due  to  the  local  action  of  the  trypsin  of  the  pancreatic  juice, 
freely  admitted  to  the  stomach  after  the  usual  lateral  anastomosis 
employed  in  this  operation. 

Prognosis  after  Gastrostomy  and  Jejunostomy.  Still  other 
paUiative  operations  may  be  employed:  gastrostomy  in  patients  with 
.carcinoma  of  the  cardiac  orifice,  and  jejunostomy  where  the  stomach 
is  too  extensively  diseased  for  the  performance  of  gastro-jejunostomy. 
^likuHcz  observed  46  patients  with  cancer  of  the  cardia.  Gastros- 
tomy was  done  in  27  (58.7  per  cent.)  of  these.  Jejunostomy  was 
employed  in  12  cases.  Moynihan  employed  gastrostomy  in  5  pa- 
tients, wdth  no  immediate  mortahty.  One  patient  lived  17  months. 
Of  three  patients  treated  by  jejunostomy,  none  died  as  the  result  of 
the  operation,  and  one  survived  as  long  as  11  weeks. 

Among  241  patients  with  cancer  of  the  stomach,  of  whom  211 
were  operated  on,  Braun  employed  gastrostomy  twice,  and  jejunostomy 
twice;  the  results  are  not  stated.  Maydl,  according  to  Riche,  re- 
ported in  1903,  27  jejunostomics  for  cancer,  with  5  deaths,  and  only 
I  death  among  the  last  five  operations — a  total  mortality  of  18.5 
per  cent.  He  compares  this  mortality  with  that  following  gastro- 
jejunostomy for  carcinoma;  but  as  Riche  points  out,  Maydl  ad- 
vocated jejunostomy  in  cases  where  others  would  do  gastro-jejun- 
ostomy, and  did  not  reserve  it  for  patients  who  were  nearly  moribund, 
as  it  is  the  custom  of  most  surgeons  to  do. 

Duodenostomy  (above  the  bile  papilla)  has  been  employed  suc- 
cessfully by  Hartmann,  and  he  advocates  it  as  in  every  way  superior 
to  jejunostomy.     We  have  had  no  experience  with  it. 

Jl  is  our  opinion  that  such  palliative  operations  as  tliesc  are  very 
rarely  inrh'cated.  Jt  is  very  unusual,  as  Dawson  has  recently  re- 
minded us,  for  thirst  to  be  an  annoying  sym])t()m  of  carcinoma  of  the 
oesophagus  or  of  the  cardiac  orifice  of  the  slomacli;  and  we  consider 
his  strong  condemnation  of  such  meddlesome  surgery  fully  justified 


Treatment.  297 

by  the  trend  of  thought  today.  So  long  as  patients  with  inoperable 
internal  carcinoma  are  not  starving  to  death,  it  is  the  part  of  wisdom 
to  refrain  from  palliative  and  useless  operations. 

Treatment. — Having  pointed  out  in  the  section  on  Prognosis,  the 
expectation  of  hfe  and  the  hope  of  radical  cure  which  operative  treat- 
ment offers  to  patients  with  carcinoma  of  the  stomach,  it  next  becomes 
necessary  to  decide  upon  the  special  type  of  operation  to  be  adopted 
in  specific  cases  of  the  disease. 

The  terminology  of  gastric  surgery  is  not  entirely  uniform  through- 
out the  surgical  world.  The  terms  as  used  in  this  volume  are  defined 
in  the  chapter  on  the  Technique  of  Operations  on  the  Stomach  (Chap- 
ter XIV),  and  to  that  the  reader  is  referred  for  detailed  descriptions. 

Total  gastrectomy  will  very  rarely  be  advisable.  Such  extensive 
invasion  of  the  gastric  wall  as  to  make  this  operation  requisite  Vv'ill 
usually  be  found  to  be  accompanied  by  so  many  perigastric  adhesions 
or  by  such  obvious  metastases,  as  to  render  useless  any  but  a  palliative 
operation.  Though  successful  in  a  sufficiently  large  number  of  cases 
to  remove  the  procedure  from  the  realm  of  mere  surgical  experiment, 
it  is  not  an  operation  which  any  surgeon  should  feel  himself  competent 
to  undertake,  save  one  who  has  been  thoroughly  trained  in  gastro- 
intestinal surgery. 

Subtotal  gastrectomy  is  more  difficult  than  partial  gastrectomy 
only  where  adhesions  abound.  If  there  are  extensive  adhesions  to 
the  pancreas,  any  form  of  gastrectomy  must  usually  be  inadvisable. 
Although  in  a  few  cases  portions  of  the  pancreas  have  been  excised 
in  one  mass  with  the  stomach,  yet  the  danger  from  infection,  and  from 
the  digestive  action  of  the  pancreatic  juice  is  so  great,  that  the  surgeon 
is  rarely  justified  in  exposing  his  patient  to  the  greater  risk,  especially 
as  freedom  from  recurrence  in  these  cases  is  not  to  be  anticipated. 
The  raw  surface  of  the  pancreas  usually  must  be  covered  in  with  gauze 
packs,  and  the  patient's  convalescence  is  thus  much  more  delayed 
than  when  the  abdominal  incision  can  be  completely  closed.  Yet 
Childe  successfully  excised  a  layer  of  pancreatic  tissue  in  one  piece 
with  the  stomach  and  the  transverse  colon,  and  Sauve  has  just  pub- 
lished a  paper  advocating  partial  pancreatectomy  when  necessar}\ 

Excision  of  the  transverse  colon  en  masse  with  the  cancerous 


298       Malignant  Diseases  of  the  Stomach :   Carcinoma. 

stomach  appears  to  have  been  employed  in  no  less  than  14  cases,  with 
9  recoveries  and  5  deaths;  the  mortality  (36.7  per  cent.)  is  thus  con- 
siderably less  than  might  have  been  expected  from  so  extensive  an 
operation.  Kocher  has  done  this  operation  in  live  patients,  two  of 
them  recovering,  and  death  in  one  of  the  fatal  cases  being  due  not  to 
the  operation  itself,  but  to  pneumonia  five  weeks  after  the  operation. 
It  is  an  operation  which  is  logically  correct,  when  the  transverse  colon 
is  itself  invaded,  but  not  to  such  an  extent  as  to  prevent  entire  removal 
of  the  malignant  growth;  and  even  in  cases  where  the  blood  supply 
of  the  colon  is  jeopardized  by  the  radical  removal  of  the  gastric  dis- 
ease (as  in  Childe's  patient,  referred  to  above,  and  in  Krause's  patient), 
even  though  the  colon  be  not  itself  invaded  by  carcinoma,  it  is  better 
successfully  to  remove  an  organ  whose  blood  supply  is  destroyed,  than 
to  expose  the  patient  to  almost  certain  death  from  gangrene  of  the 
colon.  In  a  few  instances  (Massmann,  Ross,  and  others),  the  mid- 
dle cohc  artery  has  been  unwittingly  ligated  in  doing  a  gastrectomy, 
and  the  patients  have  died  from  peritonitis  due  to  the  ensuing  gan- 
grene of  the  transverse  colon. 

RESECTION  EN  MASSE  OF  STOMACH  AND  TRANSVERSE  COLON. 

Cases.  Deaths. 

1.  Childe.     Patient  in  good  health  four  months  later i  o 

2.  Creite.     Patient  died   over  two  years  later,   without  local 

recurrence,  but  with  metastatic  growths  in  the  liver,   i  o 

3.  Fischer.     In  1888  excised  cancer  of  anterior  gastric  wall, 

with  transverse  colon  and  overlying  abdominal  wall. 

Lived  five  months i  o 

4.  Gal  let.     In  iSgg  did  excision  of  whole  stomach  and  whole 

transverse  colon;   patient  in  good  health  six  months 

later i  o 

5.  Hentschel  and   Reichel.     In   1894  did  resection  of  gastric 

wall  and  excision  of  transverse  colon  for  carcinoma. .    i  i 

6.  Kocher.     One  fatal  case  due  to  pneumonia  five  weeks  after 

operation 5  3 

7.  Krause.     Ligation  of  middle  colic  artery  requisite  for  com- 

fjletion  of  gastrectomy.  Transverse  colon  found 
blue  and  cold  at  end  of  operation.  On  account  of 
collajjse  of  patient  the  colon  was  isolated  with  gauze 
packs,  and  resection  postponed  to  next  day.  Pa- 
tient in  good  health  five  months  later i  o 

8.  McCormick  and  Welsh.     Operation  for  sarcoma  of  stom- 

ach.    See  p.   306 I  o 

9    Moynihan 2  i 

14  5 


Treatment.  299 

Partial  gastrectomy  is  the  operation  of  choice  for  the  radical 
cure  of  gastric  carcinoma.  As  already  remarked  the  differences  be- 
tween it  and  subtotal  gastrectomy  are  slight,  in  regard  to  difficulty  of 
performance,  immediate  mortality,  or  operative  technique.  Sub- 
total gastrectomy  is  necessitated  by  a  more  extensive  invasion  of  the 
neoplasm  toward  the  fundus  and  along  the  greater  curvature.  The 
question  of  most  interest  in  this  connection,  in  regard  to  partial  gas- 
trectomy, is  the  method  to  be  adopted  for  restoring  the  continuity  of 
the  gastro-intestinal  canal.  These  methods  are  Billroth's  first  method; 
Billroth's  second  method;  Kocher's  method;  and  posterior  trans- 
mesocolic  gastro-jejunostomy — which  latter  procedure  includes  sev- 
eral subvarieties,  as  the  long  loop  method  (with  or  without  entero- 
anastomosis),  the  no  loop  method,  the  Y-method,  etc.  Full  descrip- 
tions of  these  various  methods  will  be  found  in  Chapter  XIV. 

Billroth's  first  method  is  nearly  universally  condemned.  Accord- 
ing to  Paterson  leakage  at  the  ''fatal  angle"  occurred  in  23  per  cent, 
of  the  cases  he  collected.  Kocher  quotes  Guinard's  collective  statis- 
tics, of  148  gastrectomies  by  Billroth  I,  with  a  mortality  of  35.3  per 
cent. 

Billroth's  second  method  (anterior  gastro-jejunostomy),  though 
inferior  in  our  judgement  to  an  operation  completed  by  a  posterior 
trans-mesocolic  gastro-jejunostomy,  is  more  widely  applicable  than 
the  latter,  especially  in  cases  of  subtotal  gastrectomy,  when  the  cardiac 
pouch  is  small.  Unless  it  is  contra-indicated,  our  preference  is  for 
the  restoration  of  the  gastro-intestinal  canal  by  posterior  trans-meso- 
colic gastro-jejunostomy,  by  the  "no-loop"  method.  Difficulty  of 
performance,  as  after  subtotal  gastrectomy,  is  the  chief,  indeed  almost 
the  only  valid,  contra-indication. 

Kocher's  method  is  of  course  strenuously  supported  by  its  author. 
He  quotes  Guinard's  collective  statistics  of  64  operations  by  this 
method,  with  a  mortality  of  15.6  per  cent.  In  the  hands  of  Kocher 
and  his  associates  this  operation  has  been  employed  92  times,  with  14 
deaths,  a  general  mortality  of  15.2  per  cent.  (12  deaths  among  the  first 
71  operations,  or  a  mortality  of  16.9  per  cent.;  and  2  deaths  among 
the  last  21  operations,  a  mortality  of  only  9.5  per  cent.).  Kocher 
further  calls  attention  to  the  fact  that  all  but  three  of  the  patients 


300       Malignant  Diseases  of  the  Stomach:    Carcinoma. 

permanently  cured  were  operated  on  by  this  method;  of  these  three, 
one  patient  was  operated  on  by  Billroth's  first  method;  and  in  two 
patients  the  operation  was  circular  (cylindrical)  gastrectomy. 

The  operations  of  cylindrical  gastrectomy  and  of  gastric  re- 
section are  very  rarely  indicated  in  cases  of  malignant  disease.  In 
carcinoma  involving  only  the  median  portion  of  the  stomach,  the 
former  may  sometimes  be  available,  but  the  rule  enunciated  by 
Leriche,  himself  one  of  the  chief  advocates  of  cylindrical  gastrectomy, 
should  be  strictly  enforced — namely,  that  cylindrical  gastrectomy  is 
absolutely  contraindicated  if  there  are  enlarged  glands  in  the  gastro- 
hepatic  omentum;  since  under  these  conditions  it  is  imperative  for 
the  surgeon  to  remove  the  entire  lesser  curvature. 

Gastric  resection  is  suitable  only  for  tumors  confined  to  the  an- 
terior or  the  posterior  wall  of  the  stomach,  and  involving  neither 
curvature;  or  for  those  confined  to  the  greater  curvature  alone,  at  the 
fundus.  How  extremely  rare  such  growths  are,  is  recognized  by  all; 
and  even  should  it  seem  possible  to  adopt  this  operation,  the  execu- 
tion of  a  typical  partial  or  subtotal  gastrectomy  would  not  only  prove 
easier,  in  most  cases,  but  would  ofler  a  greater  chance  of  ultimate 
cure. 

Gastrostomy  is  applicable  only  to  cancer  of  the  cardiac  orifice 
or  of  the  oesophagus.  We  think  it  should  seldom  or  never  be  em- 
ployed; certainly  not  in  the  case  of  patients  who  can  still  swallow 
liquids. 

Jejunostomy  or  Duodenostomy  may  occasionally  be  adopted 
in  cases  c>f  dilTuse  infiltration  of  the  gastric  walls  not  admitting  of 
gastro-jejunostomy.  In  employing  either  gastrostomy  or  jejunostomy, 
the  precarious  state  of  the  patient  must  be  kept  in  mind;  it  is  best  for 
the  surgeon  to  knf)W  Ijcfore  beginning  the  operation  just  what  he  in- 
tends to  do,  and  then  to  do  it  without  any  unnecessary  intra-abdominal 
explorations.  By  heeding  this  advice,  and  by  adoj^ting  these  opera- 
tions as  soon  as  a  f]iagnf)sis  is  made,  instead  of  waiting  unlil  the  pa- 
tient has  one  fool  ah^cad}'  in  llie  gra\c,  ihe  surgeon  may  ex])ecl  liis 
immerh'ate  mortaJit}-  to  be  almost  ;///,  and  hi.s  jialienls  reallv  to  dcri\e 
some  benefit  from  the  operation. 


References.  301 

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Berg:    Hygiea,  Stockholm,  1907,  Ixix,  225;    cited  in  Jour.    Amer.    Med. 

Assoc,  1907,  ii,  2048. 
Bernoulli:   Arch.  f.  Verdauungskrankh.,  1907,  xiii,  118. 
Boas:   Cited  by  Kausch,  Berlin,  klin.  Woch.,  1907,  xliv,  509;    574. 
Braun:   Cited  by  Creite,  loc.  infra  cit. 
Bryant:    Cited  by  Van  Valzah   and    Nisbet,    Diseases    of   the    Stomachy 

London,  1900,  p.  513. 
Childe:   Brit.  Med.  Jour.,  1906,  i,  194. 
Creite:   Deutsch.  Zeit.  f.  Chir.,  1907,  Ixxxvii,  275;   291. 
Crile:   Ohio  State  Med.  Jour.,  1908,  iv,  80. 

Cuneo:  Hartmann's  "Travaux  de  Chir.  Anat.-Clin.,"  Paris,  1903,  i,  244. 
Dawson:  Brit.  Med.  Jour.,  1908,  i,  1089. 
Deaver:   N.  Y.  State  Jour,  of  Med.,  1906,  vi,  64. 
Deaver:   Amer.  Jour.  Med.  Sc,  1907,  i,  535. 

Deaver:  Archives  of  Diagnosis,  1908,  i,  244.     (Sarcoma  of  Ovary.) 
Dowd:   N.  Y.  Med.  Record,  1906,  i,  91. 
Engelhorn:    Beitr.  z.  Geb.    u.  Gynak.,    1907,    xi.    No.  2;    cited  in  Jour. 

Amer.  Med.  Assoc,  1907,  ii,  i960. 
Ewing:   Archives  of  Internal  Med.,  1908,  i,  175.  . 
Fenwick:  Cancer  and  Other  Tumours  of  the  Stomach,  London,  1902. 
Fischer:    Centralbl.  f.  Chir.,  1888,  xv,  Beil.,  S.  47. 
Gallet:    Cited  by  Monprofit,  Arch.  Provinciales  de  Chir.,  1906,  xv,  26. 
Hartmann:   Bull,  et  Mem.  Soc  Chir.  Paris,  1904,  xxx,  198. 
Hayem:     Revue  de  Chir.,  1908,  i,  867.     (Frequency  of  mahgnant  changes 

in  gastric  ulcer.) 
Hayem:   Bull,  et  Mem.  Soc.  Hopitaux,  Paris,  1895,  xii,  327. 
Hentschel   and    Reich  el:    Cited    by    Chavannaz:    Revue  de    Gyn.  et   de 

Chir.  Abd.,  1907,  xi,  527. 
Jacobi:   Jour.  Amer.  Med.  Assoc,  1906,  xlvii,  1545. 
Jamieson  and  Dobson:   Lancet,  1907,  i,  106 1. 

Jedlicka:  Operat.  Behandl.  d.  chron.  Magengeschwurs,  Prag  1904,  S.   24. 
Katzenstein:  Berl.  klin.  Woch.,  1906,  xliii,  1492 ;  Medical  Press,  1906,  ii,  621. 
Kausch:   Berl.  klin.  Woch.,  1907,  xliv,  509;   574. 
Kocher:   Corr.-Bl.  f.  Schweizer  Aerzte,  1907,  xxxvii,  265. 
Krause:    Cited   by    Maragliano,    Deutsch.    med.    Woch.,     1902,    xxviii, 

Ver.-BeiL,  369. 
Kronlein:    Moynihan's  Abdominal  Operations,  Phila.,  1905,  p.  218. 
Leriche:  Annales  Internat.  de  Chir.  Gastro-Intest.,  1907,  i,  100. 
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Lieblein  and  Hilgenreiner:   Die  GeschwiJre  u.  d.  erworbenen  Fisteln  d. 

Magen-Darmkanals,    Stuttgart,    1905,    S.    437.      Deutsche 

Chir.,  Lief.  46  c 
Massmann:   Dissert.,  Kiel,  1904.     (This  work  has  not  been  accessible.) 
Mayo:  Jour.  Amer.  Med.  Assoc,  1905,  ii,  1211. 


302       Malignant  Diseases  of  the  Stomach:   Carcinoma. 

Mayo:  Annals  of  Surgery,  1907,  i,  810. 

McCormick  and  Welsh:   Scottish  Med.  and  Surg.  Jour.,  1906,  xix,  299. 

Menetrier:    Compt.-Rend.   XIII    Congr.    Inter,    d.    Med.,    Paris    1900, 

Sect.  d.  Pathol.  Gen.  et  Exper.,  p.  321. 
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Monprofit:  Arch.  Prov.  de  Chir.,  1905,  xiv,  641. 
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York,  1905,  pp.  87;   201. 
Odier:  Presse  Med.,  1908,  p.  121. 

Paterson:   Gastric  Siirgery,  New  York,  1906,  pp.  106,  107. 
Riche:   BuU.  et  Mem.  Soc.  Chir.  Paris,  1904,  xxx,  170. 
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New  York,  1904,  p.  103. 
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Zirkelbach:   Arch.  f.  Verdauungskrankh.,  1906,  xii,  543. 


CHAPTER  XII. 

MALIGNANT  DISEASES  OF  THE  STOMACH  AND 
DUODENUM:  SARCOMA. 

Sarcoma  of  the  stomach  has  been  considered  a  rare  disease.  But 
Fenwick  observed  two  examples  of  round  cell  sarcoma  among 
"twenty-three  consecutive  autopsies  upon  persons  who  had  died 
from  primary  neoplasms"  of  the  stomach;  and  Perry  and  Shaw 
found  four  sarcomata  among  fifty  museum  specimens  of  mahgnant 
tumors  of  the  stomach.  Some  of  the  cases  recorded  as  such  probably 
are  not  true  sarcomata.  Hosch  has  collected  102  cases  of  primary 
gastric  sarcoma.  He  found  among  13,387  autopsies,  recorded  in  the 
University  of  Basel,  that  there  were  168  instances  of  sarcoma;  and 
that  6  of  these  (3.5  per  cent,  of  the  sarcomata)  were  primary  in  the 
stomach.  According  to  Mikulicz  and  Kausch  sarcoma  forms  from 
5  to  8  per  cent,  of  all  primary  tumors  of  the  stomach.  The  metastatic 
is  much  less  rare  than  the  primary  form. 

Yates  found  from  a  study  of  the  literature  that  from  28  to  45  per 
cent,  of  the  reported  tumors  were  of  the  round  cell  variety,  from  32 
to  36  per  cent,  of  the  spindle  cell  form,  while  lymphosarcoma  con- 
stituted from  15  to  35  per  cent,  of  cases.  Mixed  tumors  are  frequent, 
among  those  encountered  being  the  myxomatous  and  the  angioma- 
tous; fibro-sarcomata  and  myo-sarcomata  also  are  not  unusual.  Cvsts 
may  form  from  hemorrhages  or  necrotic  processes  in  the  central  parts 
of  the  tumor.  Indeed  it  is  not  unfrequently  impossible  for  even  a 
skilled  pathologist  to  determine  whether  such  a  tumor  is  a  myoma,  a 
myxoma,  an  angeioma,  or  a  true  sarcoma;  and  when  the  existence  of 
a  mixed  form  is  indubitable,  it  may  be  impossible  to  say  whether  the 
angeioma,  the  myoma,  etc.,  was  the  primary  growth  and  was  origin- 
ally benign,  or  whether  the  tumor  was  malignant  (sarcomatous)  ab 
initio.  This  uncertainty  was  noted  when  describing  benign  tumors  of 
the  stomach,  and  is  merely  recalled  here  in  passing,  since  any  dis- 

303 


304  Malignant  Diseases:    Sarcoma. 

cussion  of  moot  points  in  pathology  would  be  out  of  place  in  a  work 
of  this  kind. 

Under  the  title  of  endothehoma  carcinomatosum  von  Bergmann 
(cited  by  Borrmann)  described  a  tumor  within  the  layers  of  the 
great  omentum  so  firmly  attached  to  the  stomach  at  its  greater 
curvature  near  the  pylorus,  that  resection  of  the  gastric  wall  was  re- 
quired. It  was  a  cystic  tumor,  and  in  Borrmann's  opinion  its  point 
of  origin  was  the  stomach. 

The  sarcomatous  growth  usually  commences  in  the  submucous 
tissues,  and  the  mucosa  may  remain  intact  for  a  considerable  time. 
The  tumor  frequently  attains  a  considerable  size,  and  may  project 
into  the  cavity  of  the  stomach  or  may  protrude  beneath  its  serous  coat, 
sometimes  invading  the  gastro-hepatic  or  the  gastro-coHc  omentum. 

Gastric  sarcoma  has  been  found,  according  to  Yates,  at  the  car- 
diac orifice  in  6  per  cent,  of  cases,  at  the  fundus  in  58  per  cent.,  at  the 
pylorus  in  only  36  per  cent,  (compared  to  60  per  cent,  of  carcinomata 
found  at  the  pylorus);  and  no  more  than  9  per  cent,  of  those  at  the 
pylorus  produced  obstruction.  About  one-third  of  the  tumors  were 
more  or  less  dift'use.  Yates  found  that  metastasis  was  noted  in  70  per 
cent,  of  the  round  cell  sarcomata  and  lympho- sarcomata,  and  in  less 
than  50  per  cent,  of  the  spindle  cell  variety.  The  kidneys  (in  28  per 
cent.j;  the  liver,  ovaries,  pancreas,  adrenals  and  omentum  (each  in 
14  per  cent.);  and  the  lungs,  diaphragm,  pleura?,  oesophagus,  intestine, 
and  mesentery  (in  about  7  per  cent.),  are  the  organs  most  often  in- 
volved (Fenwick).  The  skin  presented  metastatic  nodules  in  about 
1 2  per  cent,  of  the  reported  cases.  Hosch  calls  particular  attention 
to  the  fact  that  whereas  sarcomata  in  general  (throughout  the  body) 
give  metastases  to  the  liver  in  40  per  cent,  of  cases,  those  which  were 
primary  in  the  stomach  j^roduced  secondary  hcpalic  growths  in  only 
one-tenth  of  the  recorded  cases. 

Symptoms. — The  symptoms  due  to  the  presence  of  a  malignant 
growth,  namely,  anaemia,  emaciation,  etc.,  are  similar  to  those  en- 
countered in  patients  with  gastric  carcinoma;  but  pyloric  obstruction,, 
which  is  usual  in  the  latter  disease,  is  seldom  seen  in  cases  of  sarcoma 
of  the  stomach;  and  a  history  of  long  standing  dyspepsia  is  also  rare. 
Tests  of  the  gastric  secretion  give  results  similar  to  those  obtained  in 


Treatment.  305 

carcinoma.  Fenwick  lays  stress  upon  the  great  enlargement  (non-ma- 
lignant) of  the  spleen,  in  15  per  cent,  of  patients  with  sarcoma  of  the 
stomach;  this  enlargement,  when  present,  is  an  important  differential 
sign.  Perforation  is  said  to  be  more  frequent  (11  per  cent.)  than  in 
carcinoma  of  the  stomach.  Hemorrhage  is  characteristic  of  the  an- 
geiomatous  and  myomatous  forms.  Carcinoma  and  sarcoma  have 
been  found  associated  twice  in  the  stomach. 

Diagnosis  from  carcinoma  is  rarely  possible  before  operation, 
and  often  a  distinction  can  be  reached  only  by  microscopical  exami- 
nation. The  age  of  the  patient  is  an  unrehable  guide:  among  70 
cases  where  the  age  was  recorded,  Hosch  found  27  patients  under 
40  years  of  age,  26  over  50  years  of  age,  and  17  (the  greatest  number 
in  any  decade)  between  40  and  50  years.  The  very  marked  pros- 
tration of  strength,  the  excessive  ansemia,  and  the  early  occurrence 
of  slight  but  persistent  pyrexia,  all  speak  in  favour  of  sarcoma.  When 
the  abdomen  is  opened,  one  would  be  inclined  to  diagnosticate  sar- 
coma from  the  existence  of  a  well  defined  tumor,  especially  if  of  rather 
large  size,  not  obstructing  the  pylorus,  softer  and  more  vascular  than 
a  carcinoma,  situated  on  one  of  the  gastric  walls  or  at  the  fundus, 
rather  than  along  the  lesser  curvature;  and  from  the  absence  of  peri- 
gastric adhesions. 

Prognosis.  Without  operation  the  average  duration  of  life  is 
"fifteen  to  eighteen  months  for  the  round  cell,  and  twenty- four  to 
thirty- two  months  for  the  spindle  cell  forms,  both  distinctly  longer 
than  carcinoma."     (Yates.) 

Treatment. — If  a  satisfactory  diagnosis  cannot  be  reached 
within  a  few  weeks,  exploration  should  be  urged.  To  the  24  oper- 
ations for  sarcoma  of  the  stomach  collected  by  Lecene  and  Petit,  m.ay 
be  added  8  since  reported  (Yates  (4  cases),  McCormick  and  Welsh 
(2  cases),  Halsted,  Oberst).  The  result  in  two  of  these  latter  cases 
(reported  by  Yates)  is  not  recorded.  Of  the  30  operations  whose 
outcome  is  recorded,  17  patients  recovered,  and  13  died,  a  total  mor- 
tality of  43.33  P^r  cent. 

The  following  table,  modified  from  that  of  Lecene  and  Petit, 
shows  the  operations  employed,  the  number  of  patients,  with  the 
results. 


3o6  Malignant  Diseases:  Sarcoma. 

OPERATIONS  FOR  GASTRIC  SARCOMA. 

Cases.  Rec.  Died. 

Exploration i  o  i 

Gastro-enterostomy 6  i  5 

Gastrectomy 8  5  3 

Gastric  resection 11  10  i 

Resection  of  tumor  and  transverse  colon  (see  page  298) i  o  i 

Drainage  of  subacute  perforation i  o  i 

Tumor  removed  without  opening  stomach i  i  o 

False  anus  for  chronic  obstruction  of  colon i  o  i 

30  17  13 

Considering  alone  those  cases  where  radical  operation  was  done, 
we  have  a  total  of  21  operations,  with  5  deaths,  or  a  mortality  rate  of 
less  than  24  per  cent. 

Of  twelve  patients  who  recovered  from  operation,  referred  to  by 
Corner  and  Fairbank,  four  were  reported  as  being  alive  and  well  after 
4,  5,  12  and  24  months  respectively  since  operation.  According  to 
Lecene  and  Petit,  three  patients  were  reported  well  over  one  year 
after  the  operation,  and  one  of  these  three  (operated  on  by  Capello) 
was  well  more  than  two  years  after  the  operation. 

REFERENCES. 

V.  Bergmann:  Petersb.  med.  Woch.,  1897,  xxii,  Heft.  3;  cited  by  Borr- 
mann:  Mitth.  a.  d.Grenzgeb.  d.  Med.  u.  Chir.,  1900,  vi,  543. 

Corner  and  Fairbank:   Trans.  Path.  Soc.  London,  1905,  Ivi,  32. 

Fenwick:  Cancer  and  Other  Tumours  of  the  Stomach,  London,  1902, 
p.  274. 

Halsted:  Annals  of  Surgery,  1906,  ii,  638. 

Hosch:   Deutsch.  Zeit.  f.  Chir.,  1907,  xc,  98. 

Lecene  and  Petit:   Revue  de  Gyn.  et  de  Chir.  Abd.,  1904,  viii,  965. 

McCormick  and  Welsh:  Scottish  Med.  and  Surg.  Jour.,  1906,  xix,  299. 

Mikulicz  and  Kausch:  System  of  Practical  Surgery,  ed.  by  v.  Bergmann 
and  Bull,  Phila.,  1904,  iv,  369. 

Oberst:    Bcitr.  z.  klin.  Chir.,  1905,  xlv,  477. 

Yates:   Annals  of  Surgery,  1906,  ii,  599. 


Carcinoma  of  the  Duodenum.  307 


MALIGNANT  DISEASES  OF  THE  DUODENUM. 

Carcinoma.— This  affection  is  rare.  Ewald  found  only  19 
carcinomata  of  the  duodenum  among  11 48  cases  of  intestinal 
carcinoma.  Perry  and  Shaw,  among  18,000  autopsies,  found  4 
carcinomata  (0.05  per  cent.)  and  6  sarcomata  of  the  duodenum. 
Fen  wick  found  18  carcinomata  of  the  duodenum  among  19,518 
autopsies  (0.09  per  cent.).  He  calculated  therefore  that  cancer 
occurs  only  once  in  the  duodenum  for  over  twenty  times  it  is  found  in 
the  stomach. 

Duodenal  carcinoma  is  usually  described  according  to  the  rela- 
tion it  bears  to  the  bile  ducts,  as  supra-ampullary  (para-pyloric), 
juxta-ampullary  (peri-ampuUary),  and  infra-ampullary  (juxta-jejunal). 
Of  these  forms  the  juxta-ampullary  is  the  most  frequent.  Schiiller 
collected  41  cases  of  primary  malignant  tumoi?  of  the  orifice  of  the 
common  bile  duct.  Among  51  cases  of  duodenal  carcinoma  collected 
by  Fenwick,  11  (21.5  per  cent.)  involved  the  first  part;  29  (57  per 
cent.)  were  in  the  second  or  descending  portion;  and  7  (13.5  per  cent.) 
in  the  third  (transverse)  portion.  In  the  remaining  cases  (8  per  cent.) 
the  duodenum  was  diffusely  infiltrated  by  the  malignant  growth. 

Apart  from  the  supposition  that  duodenal  carcinoma  usually 
developes  from  a  preceding  ulcer,  little  is  known  of  the  aetiology. 
The  studies  of  Menetrier  on  this  subject  were  referred  to  at  p.  271. 
Mayo  reports  having  observed  three  cases  of  primary  carcinoma  of 
the  duodenum,  in  one  of  which  certainly,  and  in  a  second  probably, 
the  malignant  growth  was  engrafted  on  a  previously  existing  benign 
ulcer.  In  the  third  case  the  disease  was  too  far  advanced  for  any 
decision  to  be  reached. 

Most  duodenal  carcinomata  are  of  the  cylindrical  celled  variety 
(adeno-carcinoma).  The  growth,  especially  when  adeno- carcinoma, 
usually  constricts  the  intestine,  and  symptoms  of  obstruction  are 
therefore  prominent.     When  viewed  from  outside  the  gut,  the  ap- 


J) 


08  Malignant  Diseases   of  the  Duodenum. 


pearance  is  as  if  a  "string  had  been  tied  tightly  around  the  bowel" 
(Fen wick).  If  above  the  bile  papilla,  the  symptoms  of  pyloric  ob- 
struction are  so  closely  simulated  as  to  make  a  correct  diagnosis  ex- 
tremely difficult,  if  not  impossible.  When  upon,  or  in  the  immediate 
neighbourhood  of  the  biliary  opening,  chronic  jaundice  is  present,  and 
diflferentiation  from  stone  in  the  common  duct,  from  chronic  pan- 
creatitis, etc.,  becomes  important.  Dilatation  of  the  stomach,  usually 
absent  in  affections  confined  to  the  biliary  and  pancreatic  tracts,  is  an 
important  differential  sign.  These  matters  will  be  more  fully  dis- 
cussed in  our  second  volume.  Below  the  orifice  of  the  common  bile 
duct,  obstruction  of  the  duodenum  is  less  difficult  to  diagnosticate: 
the  nearly  constant  presence  of  bile  in  the  vomitus  is  a  most  important 
symptom.  If  this  were  due  to  a  gastro-biliary  fistula,  instead  of 
regurgitation  of  bile  from  the  duodenum,  the  vomitus  would  not  be 
found  to  contain  the  pancreatic  ferments  as  well  as  bile. 

Operation  must  usually  be  palliative — gastro-jejunostomy  being 
the  procedure  likely  to  produce  most  comfort.  Maylard's  patient 
lived  several  months  after  cholecystostomy.  Syme  resected  three 
inches  and  a  half  of  the  third  portion  of  the  duodenum  for  an  annular 
carcinoma,  restoring  the  intestinal  canal  by  end  to  end  anastomosis  of 
the  duodenum  by  suture.  His  patient  recovered  and  was  in  good 
health  three  months  later.  Schiiller  refers  to  ten  palliative  operations 
for  carcinoma  of  the  biliary  orifice;  one  patient  lived  two  years,  but 
the  majority  died  in  a  few  days.  In  one  case  Czerny  (cited  by  Schiiller) 
did  transduodenal  excision  of  such  a  growth,  re-implanting  the 
common  duct  into  another  part  of  the  duodenum;  his  patient  died  8 
days  later,  and  autopsy  showed  that  a  radical  operation  was  useless  as 
there  were  already  metastases  in  the  liver.  In  one  patient  at  the 
German  Hospital,  Dr.  Deaver  excised  from  Ihf  juxta-])yloric  j)ortion 
of  the  duodenum  a  small  nut-si/ed  tumor  found  on  microsc()i)ical 
examination  to  be  carcinomatous.  The  jjatient  recovered,  and  was 
in  good  health  over  i  year  after  the  operation. 

Sarcoma  of  the  duodenum  has  been  repoiitd  in  al)oul  21  cases 
(Fenwick).  Obstruction  is  rare,  the  tumor  ])cing  rather  soft  and 
va.scular  than  constricting.  l'"atal  hemorrhage  has  been  noted 
(RoUcston). 


Malignant   Diseases  of  the  Duodenum.  309 


REFERENCES. 

Deaver:  Archives  of  Diagnosis,  1908,  i,  244. 

Fenwick:    Cancer  and   Other  Tumours  of  the   Stomach,   London,    1902, 

p.  284. 
Maylard:   Glasgow  Med.  Jour.,  1907,  Ixvii,  306. 
Mayo:  Annals  of  Surgery,  1907,  i,  810. 
Perry  and  Shaw:   Guy's  Hospital  Reports,  1893,  1,  171. 
Schuller:  Beitr.  z.  khn.  Chir.,  1901,  xxi  683. 
Syme:   Lancet   1904,  i,  148 


CHAPTER  XIII. 

INJURIES  OF  THE  DIAPHRAGM,  STOMACH,   AND 
DUODENUM. 

Of  the  various  injuries  to  be  considered  in  this  chapter,  the  ma- 
jority are  rare  occurrences  in  civil  hospitals.  The  nationality  of 
patients  has  also  a  considerable  influence  in  determining  the  relative 
frequency  with  which  stab- wounds  and  gunshot  wounds  are  encoun- 
tered, while  subcutaneous  ruptures  are  almost  exclusively  confined  to 
city  hospitals  with  large  accident  services.  Stab- wounds  are  therefore 
more  frequent  in  southern  Europe,  and  among  Italian  laborers  in  this 
country,  than  in  other  portions  of  our  population;  while  gunshot 
wounds  are  rare  in  northern  cities,  except  from  negro  brawls,  compared 
to  their  incidence  in  the  southern  states,  where  the  experience  of  one 
surgeon  may  embrace  a  hundred  or  more  operations  for  such  injuries. 

I.  Injuries  of  the  Diaphragm. — These  are  of  interest  to  the 
abdominal  surgeon  because  of  the  frequency  of  abdominal  compli- 
cations. 

(A)  Stab-wounds.  These  usually  result  from  penetration  of  one 
of  the  lower  (sixth  to  tenth)  intercostal  spaces  on  the  patient's  left. 
The  lung  is  rarely  injured,  but  the  dagger,  if  it  penetrates  the  dia- 
phragm, not  unfrequently  punctures  the  stomach, "the  colon,  or  the 
omentum.  Among  73  operations  for  wounds  of  the  diaphragm, 
analyzed  by  Suter,  there  was  injury  of  the  abdominal  contents  in  24 
cases,  or  33.33  per  cent. 

The  symptoms  are  chiefly  those  of  shock  and  hemorrhage.  The 
omentum  frequently,  and  the  stomach  or  colon  occasionally,  protrudes 
in  the  thoracic  wound;  this  is  of  course  pathognomonic  of  penetration 
of  the  abdominal  cavity.  The  physical  signs  closely  resemble  those  of 
diaphragmatic  hernia  (see  p.  259).  Operation  should  be  undertaken 
before  sufficient  time  has  elapsed  for  evidences  of  j)eritonitis  to  appear. 

310 


Stab-wounds  of  the  Diaphragm.  311 

The  prognosis  without  operation  is  very  bad.  Sorrentino  (1895) 
refers  to  33  cases  in  which  no  operation  was  done.  Of  these  patients, 
29  died,  a  mortahty  of  87.8  per  cent.  Among  the  29  deaths,  15 
occurred  soon  after  the  injury,  giving  an  immediate  mortahty  without 
operation  of  50  per  cent.;  the  other  14  patients  hved  for  months  or 
years,  and  then  died  from  conditions  which  prompt  operation  can 
prevent.  The  causes  of  death  in  the  patients  who  died  soon  after 
injury  were  as  fohows : 

Incarceration  of  abdominal  organs  in  wound  of  diaphragm, 7  patients. 

Extravasation  of  gastric  contents  into  pleural  cavity, 5         " 

Hemorrhage, i  patient. 

Empyema, 2  patients. 

Of  those  patients  W'ho  survived  their  injuries  for  the  time  being,  every 
one  reported  died  later  from  incarceration  of  the  diaphragmatic  hernia. 
Akhough  these  figures  are  not  very  recent,  they  may  be  accepted  as  a 
fair  indication  of  what  the  outcome  of  these  cases  must  be  if  no  opera- 
tion be  employed,  as  the  non-operative  treatment  of  such  cases  has 
changed  little,  if  at  all,  since  these  statistics  were  collected. 

On  the  other  hand,  the  results  of  operation  are  very  encouraging. 
Lenormant  in  1903  collected  31  operations  for  wounds  of  the  dia- 
phragm, with  only  8  deaths,  a  mortality  of  25.8  per  cent.  Suter  in 
1905  analyzed  79  such  operations;  70  patients  recovered,  a  death  rate 
of  1 1.4  per  cent.  Of  the  9  fatal  cases,  only  2  were  unaccompanied  by 
injury  of  the  abdominal  viscera. 

Treatment.  It  being  decided  that  operation  is  indicated,  it  next 
becomes  necessary  to  determine  what  the  operation  shall  be ;  w' hether 
thoracotomy,  laparotomy,  thoraco-laparotomy,  or  a  combined  opera- 
tion (an  operation  which  opens  both  pleural  and  peritoneal  cavities 
by  means  of  a  single  incision).  Suter's  statistics  show  a  very  striking 
difference  in  the  results  which  have  attended  these  various  operations. 
If  to  Suter's  figures  we  add  14  operations  (6  original,  and  8  reported 
since  the  appearance  of  Suter's  article)  collected  by  Iselin,  as  well 
as  the  operation  recently  reported  by  Francis  T.  Stewart  to  the 
Philadelphia  Academy  of  Surgery  (January,  1908),  we  have  the  fol- 
io wing  as  the  latest  figures: 


312      Injuries  of  Diaphragm,  Stomach,  and  Duodenum. 

OPERATIONS  FOR  STAB-WOUNDS  OF  THE  DIAPHRAGM. 

Thoracotomy 65  61  4  6.15 

Laparotomy 19  14  5  26.31 

Thoraco-laparotomy 6  4  2  33-33 

"  Combined  operation " 4  3  i  25.00 

Total 94  82  12  12.7 

The  much  higher  mortality  in  cases  treated  by  laparotomy  is  not 
due,  as  might  be  supposed  at  first  sight,  to  graver  injuries  than  in  the 
cases  of  patients  treated  by  thoracotomy.  Suter  gives  the  following 
figures  for  the  24  operations  in  which  injuries  of  the  abdominal  viscera 
were  present: 

OPERATIONS    FOR    STAB-WOUNDS    OF    THE    DIAPHRAGM 
COMPLICATED  BY  INJURIES  OF  ABDOMINAL  VISCERA. 


^°-  °^        Recoverfd  Difd        Mortality 

Cases.        recovered.  uied.       p^^^  ^^.^^_ 


Operation.  t^.',.^^         Recovered.  Died. 


Laparotomy 9  5  4] 

Thoraco-laparotomv 2  i  ij'           50-00 

"  Combined  operation  " i  o  ij 

Thoracotomy 12  11  1                8.30 

The  technique  of  the  operation  is  essentially  the  same  as  that  for 
diaphragmatic  hernia,  which  has  already  been  described  (p.  265). 
By  laparotomy  it  is  usually  very  difficult,  if  not  impossible  (i)  to 
reduce  the  herniated  organs,  owing  to  the  negative  pressure  within 
the  thorax;  (2)  to  repair  the  wound  in  the  diaphragm;  (3)  to  suture 
wounds  of  the  cardia  or  the  fundus  of  the  stomach.  If  the  herniated 
viscera  can  be  reduced  from  within  the  abdomen,  pneumothorax  is 
produced  by  this  procedure  quite  as  surely  as  by  the  operation  of 
thoracotomy.  By  the  latter  operation  tlie  injured  viscera  can  be 
quite  satisfactorily  repaired,  as  well  as  the  wound  in  the  diaphragm; 
or  if  there  seem  good  reason  to  believe  that  further  abdominal  in- 
juries exist,  inaccessible  to  treatment  from  above,  the  al:)domcn  may 
be  opened  subsequently.  Pleural  infection  occurred,  according  to 
Suter,  in  less  than  10  ]jer  cent,  of  the  whole  numlxT  of  o])erations. 

REFERENCES. 

Gibbon:  Annals  of  Surgery,  igo8,  i,  634. 

Iselin:  Deutsch.  Zeit.  f.  Chir.,  1907,  Ixxxviii,  150. 


Rupture  of  the  Diaphragm.  313 

Lenormant:   Revue  de  Chir.,  1903,  xxviii,  617. 
Sorrentino:   Riforma  Medica,  1895,  ^^>  Fasc.  2,  pp.  75;   88. 
Stewart:  Annals  of  Surgery,  1908,  i,  633. 
Suter:   Beitr.  z.  klin.  Chir.,  1905,  xlvi,  341;  xlvii,  403. 

(B)  Gunshot  Wounds  of  the  diaphragm  have  no  interest  apart 
from  the  accompanying  visceral  injuries.  Yet  Robert  has  reported 
the  case  of  a  patient  who  died  from  strangulated  diaphragmatic 
hernia  one  year  after  a  gunshot  perforation  of  the  diaphragm,  from 
which  he  had  recovered  without  operation. 

REFERENCE. 
Robert:  Cited  by  Forgue  and  Jeanbrau,  Revue  de  Chir.,  1903,  xxviii,  813. 

(C)  Rupture  of  the  Diaphragm.  Subcutaneous  as  distinguished 
from  percutaneous  injuries  of  the  diaphragm  are  extremely  rare. 
Iselin  advises,  and  we  beheve  justly,  that  primary  laparotomy  be  the 
operation  of  choice  in  these  cases,  since  extensive  lesions  of  the  ab- 
dominal viscera  are  more  frequent  than  in  the  case  of  stab-wounds,  and 
hemorrhage  from  ruptured  blood-vessels  may  be  inaccessible  by  the 
thoracic  route.  If  it  be  difficult  to  reduce  the  herniated  organs,  the 
surgeon  may  create  a  pneumothorax  by  a  small  intercostal  incision, 
whereupon  reduction  will  be  easy.  After  the  more  serious  lesions 
have  been  repaired  (hsemostasis,  suture  of  gastro-intestinal  perfora- 
tions, etc.),  and  if  the  patient's  condition  permit,  the  surgeon  may 
open  the  thorax  and  suture  the  rent  in  the  diaphragm  from  above. 
If  collapse  of  the  patient  prevent  this  step  of  the  operation,  the  rup- 
ture should  be  tamponned  from  the  abdominal  wound,  in  the  hope 
that  protective  adhesions  may  form.  Omentum,  and  even  Hver  or 
stomach  might  be  sutured  in  place  to  stop  the  gap. 

It  has  been  possible  to  find  references  to  only  five  operations  for 
subcutaneous  rupture  of  the  diaphragm.     Two  patients  recovered. 

1.  Guibal.  Laparotomy  by  Villemin:  herniated  organs  reduced;  pro- 

fuse hemorrhage;  wound  hastily  tamponned.  Patient  died  in 
a  few  minutes  after  return  to  bed.  Autopsy  showed  rupture 
of  spleen,  liver  and  left  kidney. 

2.  Walker.  Laparotomy:  small  bowel  withdrawn  from  rent,  which 

it  was  impossible  to  suture.     Recovered. 


314      Injuries  of  Diaphragm,  Stomach,  and  Duodenum. 

3.  Knaggs.  Laparotomy  by  Berry,  5  days  after  injury;  hernia  re- 

duced; Kver  sutured  against  rent  in  diaphragm.   Died  on  table. 

4.  Martin.  Operation  for  incarceration  5  days  after  injury.     Died. 

5.  Suter.  Incision  as  for  nephrectomy;  suture  of  rents  in  diaphragm, 

and  left  nephrectomy.     Recovered. 

REFERENCES. 

Guibal:   Bull,  et  Mem.  Soc.  Anat.  Paris,  1900,  Ixxv,  507. 
Iselin:  Deutsch.  Zeit.  f.  Chir.,  1907,  Ixxxviii,  150. 
Knaggs:  Lancet,  1904,  ii,  359;   Case  4. 
Martin:   Cited  by  Iselin,  loc.  supra  cit. 
Suter:  Beitr.  z.  klin  Chir.,  1905,  xlvi,  341. 

(D)  Operative  Wounds  of  the  Diaphragm.  Isehn  refers  to 
four  instances  of  operative  wounds  of  the  diaphragm,  recorded  by 
Humbert,  Leisrink,  Konig,  and  Hahn.  The  operations  of  Humbert, 
Leisrink  and  Konig  consisted  in  resecting  part  of  the  diaphragm  for 
sarcoma;  that  of  Hahn  was  for  enchondroma.  Humbert  and  Konig's 
patients  recovered,  but  those  of  Leisrink  and  Hahn  died. 

REFERENCE. 

Iselin:  Deutsch.  Zeit.  f.  Chir.,  1907,  Ixxxviii,  150. 


Stab-wounds  of  the  Stomach.  315 

II.  Injuries  of  the  Stomach. — From  its  anatomical  relations, 
surrounded  by  liver,  diaphragm,  pancreas,  colon,  and  spleen,  it  is 
very  rare  to  encounter  uncomplicated  wounds  of  the  stomach.  Among 
228  cases  of  penetrating  wounds  of  the  abdomen  collected  by  Siegel 
in  1898,  the  various  viscera  were  injured  as  follows: 

Viscus  Injured.  Stabwounds.     Gonshot  Wounds. 

Stomach 4  71 

Small  intestine 12  52 

Liver 6  31 

Colon 5  15 

Spleen  and  kidneys 2  14 

Omentum,  mesenten',  etc 3  13 

32  196 

Of  532  cases  treated  without  operative  intervention,  238  recovered, 
and  294  died,  a  mortality  of  55.2  per  cent.  Of  376  cases  in  which 
operation  was  done,  182  recovered  and  194  died,  a  mortahty  of  51.6 
per  cent.  The  difference,  when  the  figures  are  thus  given,  between 
medical  and  surgical  treatment,  is  not  striking;  but  when  regard  is 
had  to  the  time  elapsing  between  the  accident  and  the  operation,  it  is 
quite  evident  that  surgery  offers  the  only  reasonable  hope  of  cure. 

OPERATIONS  FOR  PENETRATING  WOUNDS  OF  ABDOMEN. 
Operation.  Mortality. 

Within  4  hours  of  injur}' 15.2  per  cent. 

From  5  to  8  hours  after  injury 44.4    "       " 

From  9  to  12  hours  after  injury 63.6    "       " 

More  than  12  hours  after  injur}' 70.0    "       " 

(A)  Stabwounds.  The  stomach  is  one  of  the  organs  least  often 
wounded  in  penetrating  stabwounds  through  the  abdominal  wall. 
Among  75  instances  of  penetrating  wounds  of  the  stomach  collected 
by  Siegel,  there  were  only  4  cases  of  stabwound.  In  former  times 
bayonette  wounds  of  the  stomach  were  not  very  rare,  and  Tuffier  calls 
attention  to  the  fact  that  suicidal  stabwounds  are  a  cause,  especially  in 
women,  who,  in  aiming  at  the  supposed  location  of  their  heart  (below 
the  left  breast),  usually  wound  the  fundus  of  the  stomach. 

The  diagnosis  depends  more  upon  the  symptoms  than  upon  the 
position  of  the  wound.  In  rare  cases  the  stomach  may  be  penetrated 
by  a  stabwound  in  the  back  (Benoit).     As  previously  noted,  wounds 


3i6    Injuries  of  Diaphragm,  Stomach,  and  Duodenum. 


of  the  stomach  arc  not  unfrequent  comphcations  of  transpleural  per- 
forations of  the  diaphragm  (p.  310).  Shock,  vomiting  of  blood,  and 
the  escape  of  gastric  contents  through  the  wound  may  render  the 
diagnosis  of  perforation  of  the  upper  intestinal  tract  certain;  but  in  all 
cases  the  wound  should  be  explored  before  peritonitis  has  had  time 
to  develope,  for  the  question  as  to  which  viscus  is  injured  is  of 
relatively  little  importance.  In  Lyng's  case  there  was  no  doubt 
as  to  the  penetration  of  the  stomach,  since  the  instrument  (a  hay- 
fork) which  produced  the  wound,  had  pieces  of  meat  and  potato 
sticking  to  it,  and  the  patient  had  just  finished  a  meal  composed 

largely  of  these  articles. 

Treatment .  If  protrusion  of 
the  omentum  or  other  abdominal 
contents  renders  the  fact  of  pene- 
tration of  the  abdomen  certain, 
no  hesitancy  need  be  felt  in 
freely  opening  the  peritoneal 
cavity;  but  if  the  stab- wound 
is  small  and  there  is  doubt  as  to 
whether  the  blade  has  actually 
entered  the  peritoneal  cavity, 
cautious  exploration  should  be 
undertaken.  The  patient  being 
anaesthetized,  and  prepared  as 
for  an  abdominal  operation,  the 
surgeon  should  dissect  down 
layer  by  layer,  and  thus  follow  the  track  of  the  wound.  It  is  sometimes 
impossible  to  follow  a  small  stabwound  directly;  under  these  circum- 
stances it  is  best  to  lay  bare  the  abdominal  ai)oneurosis  (sheath  of  the 
rectus,  aponeurosis  of  external  ()l)li(|ue)  o\-er  a  wide  area,  and  search 
it  carefully  for  the  stabwound.  If  this  cannot  be  found,  and  it  is 
known  that  the  blade  was  ver}-  short  (that  of  a  pen-knife  for  example), 
and  if  there  are  no  other  symj;toms  of  penetration,  the  skin  incision 
may  now  be  closed,  if,  however,  it  be  ascertained  that  tlie  Ijlade  has 
penetrated  the  ajjoneurosis,  the  surgeon  should  next  lay  bare  the 
Iransversalis  fascia  and  ]K'ritoneum,  but  should   not  open  the  latter 


Fig.  30. — Diagram  to  Show  Overlap- 
ping OF  ,\nterior  Gastric  Wall  by 
Surrounding  Structures. 


Stab-wounds  of  the  Stomach. 


317 


until  he  is  sure  it  has  been  penetrated.  It  is  often  impossible  to  trace 
a  small  stab  wound  across  fatty  tissue  and  muscular  fibres;  and  it  is 
usually  inadvisable  to  make  any  attempt  to  insert  a  probe  in  the  path 
of  the  wound,  as  by  doing  so  not  only  are  false  passages  usually  pro- 
duced, but  the  probe  itself  may  penetrate  the  abdominal  cavity  when 
the  latter  had  not  been  invaded  by  the  original  instrument.  But  by 
arresting  his  dissection  at  the  aponeurotic  and  peritoneal  layers  of  the 
abdominal  wall,  the  surgeon  will  be  able  to  determine  in  almost  all 
cases  the  existence  or  the  absence  of  penetration  of  the  abdominal 
cavity.     We  are  thus  insistent  upon  this  cautious  approach,  and  upon 


Fig.  31. — Diagram  to  Show  Relations 
OF  Posterior  Gastric  Wall  to 
Surrounding  Structures. 


Fig.  32. — Diagram  Made  by  Super- 
imposing Fig.  31  on  Fig.  30  to 
Show  Close  Relations  of  Stomach 
TO  Surrounding  Structures. 


determining  beforehand  whether  the  peritoneal  cavity  has  been  pene- 
trated by  the  weapon,  because  it  often  happens  that  on  opening  the 
abdomen  widely  in  these  cases  inspection  shows  no  evidence  of  intra- 
abdominal lesion,  and  very  extensive  search  becomes  necessary  to 
exclude  the  possibility  of  visceral  injury;  and  if  none  be  found  to 
exist,  and  it  is  shown  that  the  vulnerating  weapon  itself  had  never 
opened  the  peritoneal  cavity,  the  surgeon  w^ill  have  subjected  his 
patient  to  a  quite  unnecessary  and  by  no  means  trivial  operation. 
If,  however,  the  fact  of  abdominal  penetration  has  been  definitely 


3i8      Injuries  of  Diaphragm,  Stomach,  and  Duodenum. 

determined  in  doubtful  cases  by  the  method  just  described,  the  sur- 
geon will  be  quite  justified  in  his  extensive  intra-abdominal  manipula- 
tions, even  though  no  lesion  be  found  more  serious  than  hemorrhage 
from  an  omental  vein. 

Although  the  mortality  for  penetrating  stabwounds  of  the  abdo- 
men is  in  general  about  50  per  cent.,  yet  the  earlier  the  operation,  the 
greater  the  chance  of  recovery.  Siegel  found  that  for  those  patients 
operated  on  within  the  first  twenty-four  hours,  the  mortality  was  only 
8.7  per  cent.,  considerably  less  than  for  gunshot  wounds. 

Stab-wound  of  Right  Gastro-Epiploic  Artery.— Maiocchi  has 
recently  reported  an  operation  for  a  large  hasmatoma  in  the  gastro- 
colic omentum  due  to  a  stabwound  of  the  right  gastro-epiploic  artery, 
without  other  important  lesion. 

OPERATIONS   FOR   STAB-WOUNDS  OF  THE   STOMACH. 
(Exclusive  of  Those  Through  the  Diaphragm.) 

1.  Budinger.     Laparotomy  7  days  after  injury.     Recovery. 

2.  Cahen.     Laparotomy  and  suture  three  hours  and  a  half  after 

injury.     Recovery. 

3.  Fuchsig.     Laparotomy  and  suture  after  12  hours.     Recovery. 

4.  Kirchner.     Multiple  stab- wounds  of  thorax  and  abdomen.    A  coil 

of  small  intestine,  completely  severed,  protruded  through 
thoracic  wound;  the  stomach  protruded  through  one  of  the 
abdominal  wounds.  Immediate  laparotomy:  resection  and 
end-to-end  anastomosis  of  small  intestine,  with  Murphy  but- 
ton ;  suture  of  stomach  and  diaphragm.  No  irrigation. 
Abdomen  closed  without  drainage.     Recovery  after  empyema. 

5.  Lyng.     Laj)arotomy  and  suture  after  15  hours.     Recovery. 

6.  Preindlberger.     Laparotomy  and  suture.     Recovery. 

7.  Rehn.     Laparotomy  after  9  hours.     Died. 

8.  Siegel.     Laparotomy  after  3  hours.     Recovery. 

9.  Wrigley.     Laparotomy  after  2  hours;    suture  of  wounds  in  an- 

terior and  ])ostcrior  wall.     Recovery. 

REFERENCES. 

Benoit:   Citcl  1)_\'  TulTicr,  loc.  infra  cit.,  p.   143. 
Budinger:   Arch.  f.  kliii.  Cliir.,  iHc^S,  Ivi,  Ileft.  I. 
Cahen:  Munch,  med.  \\o(li.,  1904,11,  1322. 


Gunshot  Wounds  of  the  Stomach.  319 

Fuchsig:   Wien.  klin.  Woch.,  1904,  xvii,  884. 

Kirchner:   Med.  Fortnightly,  St.  Louis,  1908,  xxxiii,  40. 

Lyng:   St.  Paul  Med.  Jour.,  1904,  vi,  124. 

Maiocchi:  Gaz.  d.  Ospedali,  in  Revue  de  Chir.,  1908,  xxxviii,  337. 

Preindlberger:   Zentralbl.  f.  phys.  Therap.  u.  Unfallh.,  1904,  i,  135. 

Rehn:  Cited  by  Siegel,  loc.  infra  cit. 

Siegel:  Beitr.  z.  klin.  Chir.,  1898,  xxi,  395. 

Tuffier:   Chir.  de  I'Estomac,  Paris,  1907,  p.  142. 

Wrigley:   Brit.  Med.  Jour.,  1907,  i,  1303. 

(B)  Gunshot  Wounds  of  the  Stomach.  In  only  32  out  of  126 
cases  of  gunshot  injuries  of  the  stomach,  collected  by  Forgue  and 
Jeanbrau,  was  this  the  only  viscus  wounded;  in  other  words,  in  about 
three  out  of  every  four  cases  gunshot  wounds  of  the  stomach  are 
complicated  by  serious  injuries  of  neighbouring  organs.  The  position 
of  the  stomach,  moreover,  is  such  that  not  only  will  it  be  liable  to 
injury  in  the  case  of  gunshot  wounds  of  the  abdomen,  but  also  in  those 
of  the  lower  thorax,  its  greater  tuberosity  reaching  as  high  as  the  fifth 
rib  on  the  left.  This  is  one  of  the  reasons  why  gunshot  wounds  of  the 
lower  thorax  give  a  higher  mortality,  and  more  urgently  call  for  opera- 
tive treatment  than  do  those  of  the  upper  portions. 

Gunshot  injuries  of  the  stomach  are  divided  by  systematic  writers 
into  (i)  Perforations — usually  double,  there  being  one  wound  of 
entrance,  and  another  of  exit;  (2)  Abrasions,  or  Excoriations — in 
which  the  gastric  wall  is  wounded  without  being  perforated;  and  (3) 
Contusions, — which  may  affect  either  the  serous  or  the  mucous  aspect 
of  the  organ. 

The  occurrence  of  only  one  perforation  in  the  stomach,  may  be 
explained  in  various  ways.  Among  112  cases  studied  by  Forgue  and 
Jeanbrau  (to  whose  excellent  monograph,  already  quoted,  surgeons 
are  indebted  for  most  of  their  modern  statistics),  in  only  13  did  no 
more  than  one  perforation  exist.  The  ball  may  never  have  entered 
the  stomach  at  all,  having  merely  struck  it  a  glancing  blow,  sufficient 
to  penetrate  its  cavity,  but  because  of  its  tangential  course  passing  on 
without  traversing  this  cavity.  In  only  3  cases  was  the  bullet  kno^^'n 
to  have  lodged  in  the  stomach.  It  may  make  its  exit  by  perforating 
the  duodenum  near  the  pylorus,  or  the  oesophagus  close  to  the  cardia; 
and  it  is  even  conceivable  that  a  second  perforation  (wound  of  exit) 


320      Injuries  ot  Diaphragm,  Stomach,  and  Duodenum. 

may  occur  in  the  small  retroperitoneal  portion  of  the  gastric  wall  below 
the  cardia,  and  that  the  second  perforation  will  thus  be  impossible  of 
discovery  from  outside  the  stomach,  as  the  serous  covering  of  the 
organ  will  have  been  wounded  in  only  one  place.  Cases  are  on  record 
in  which  the  bullet,  entering  the  stomach,  has  been  passed  subse- 
quently by  the  bowel,  and  one  in  which  the  bullet  was  vomited. 

According  to  Forgue  and  Jeanbrau  there  are  on  record  only  4 
cases  of  the  second  class  of  gunshot  wounds  of  the  stomach;  while 
contusions,  forming  the  third  class,  are  equally  rare.  In  a  patient  of 
their  o^^^l,  the  bullet  perforated  and  lodged  in  the  stomach;  it  pro- 
duced a  contusion  (undiscovered  at  operation)  of  the  mucous  mem- 
brane of  the  opposite  wall.  Although  this  patient  did  well  for  three 
days  after  operation,  he  died  eventually  from  profuse  bleeding  into 
the  stomach  from  an  ulcer  w^iich  formed  as  a  result  of  this  traumatism. 

A  distinction  is  to  be  drawn  between  gunshot  wounds  of  military, 
and  those  of  civil  life.  The  former  are  almost  always  rectihnear, 
owing  to  the  high  velocity  of  the  projectile;  and  the  bullet  as  a  rule 
perforates  the  patient's  entire  body,  unless  arrested  by  bone;  or  at 
least  lodges  beneath  the  skin  on  the  distal  side  of  the  body.  Bullets 
from  injuries  of  civil  life,  however,  are  more  easily  deflected  from  their 
course  on  entering  the  body,  and  rarely  if  ever  pass  completely  through 
the  trunk.  The  high  initial  velocity  of  the  modern  military  bullet 
gives  it  also  a  well  defined  explosive  action  on  a  hollow  viscus  if  filled 
with  fluid  or  semi-solid  matter,  provided  the  range  be  less  than  1800 
feet  TBorden);  cixil  bullets,  on  the  contrary,  owing  to  their  much 
lower  velocity,  scarcely  ever  ha^■e  an  ex])losive  effect,  even  on  a  full 
stomach. 

Symploms.  Tlie  most  imjjortant  sym])loms  are  those  of  shock 
and  interna]  hemorrhage.  Hccmatemesis  is  fref|uent.  0])eration 
(in  civil  life)  should  be  undertaken  before  evidences  of  peritonitis 
have  time  to  de\elo])c. 

Diagnosis.  Tliou^di  perforation  of  tlie  stomach  may  Ije  susj)ected 
in  any  patient  in  whom  the  wound  of  entrance  Hes  in  the  area  of 
vulnerability  of  the  stomach  (see  I'"i^.  ,:;2),  and  also  in  certain  other 
cases  where  the  l;no\vn  course  of  the  huHel  lio  in  llie  direction  of  the 
stomach,   thoiit^h   the   wound   of  entrance   ma\'   he  at   some  distance 


Gunshot  Wounds  of  the  Stomach.  321 

(loin,  thorax,  perineum,  etc.);  yet  the  only  certainty  consists  in  ex- 
ploratory laparotomy. 

Prognosis.  Apart  from  the  method  of  treatment  adopted,  the 
condition  of  the  stomach  when  wounded  has  a  most  important  in- 
fluence on  the  prognosis.  If  the  stomach  be  empty,  and  the  patient 
remain  in  the  recumbent  position  after  the  injury,  extravasation  will  be 
very  Hmited,  and  the  developement  of  peritonitis  much  delayed. 
Forgue  and  Jeanbrau  include  in  their  study  45  patients  treated  without 
operation,  and  82  patients  treated  by  laparotomy.  In  the  case 
of  the  former  patients  the  death  rate  was  46  per  cent. ;  in  the  latter  it 
was  42  per  cent.  Taking  these  figures  as  they  stand,  they  do  not  seem 
to  encourage  surgeons  in  urging  laparotomy  as  a  hfe-saving  measure. 
But  a  number,  in  fact  the  majority  of  these  operations  are  not  of 
recent  date,  and  it  is  but  reasonable  to  suppose  that  the  immediate 
mortahty  of  operations  for  gunshot  wounds  of  the  stomach  has  im- 
proved along  with  that  of  all  other  departments  of  gastric  surgery, 
since  the  date — five  years  ago — when  these  studies  were  published. 
Accordingly  it  is  no  surprise  to  find  that  among  25  recent  operations 
for  gunshot  wounds  of  the  stomach,  collected  in  1907  by  Walton 
Martin  of  New  York,  there  were  only  6  deaths — a  mortahty  of  less 
than  25  per  cent.  And  although  it  is  probable  that  both  series  of 
statistics  give  too  favourable  a  prognosis,  being  founded  on  collected 
cases,  rather  than  on  a  consecutive  number  of  cases  treated  in  one  hos- 
pital, or  by  one  surgeon;  yet  their  comparative  value,  showing  a  marked 
reduction  in  the  mortality  after  modern  operations,  is  not  affected 
by  this  circumstance.  But  even  with  the  less  recent  figures  of  Forgue 
and  Jeanbrau,  a  Httle  closer  inspection  will  show  that  the  difference  be- 
tween the  results  of  expectant  and  operative  treatment  is  quite  con- 
spicuous. If,  for  example,  we  consider  apart  those  cases  in  which  the 
stomach  was  the  only  organ  injured,  and  those  in  which  the  gastric 
lesions  were  comphcated  by  other  serious  injuries,  we  find  that  in  the 
former  class  of  patients  (19  cases),  operation  was  attended  by  a 
mortahty  of  42.10  per  cent.,  while  among  the  latter  (63  cases)  the 
death  rate  was  68.25  per  cent.;  if,  however,  no  operation  was  em- 
ployed, 46  per  cent,  of  those  patients  (13  cases)  with  only  gastric 
lesions  died,  and  93  per  cent,  of  those  (32  cases)  with  wounds  of  other 


322      Injuries  of  Diaphragm,  Stomach,  and  Duodenum. 

organs  succumbed.  As  it  is  absolutely  impossible  to  know  before 
beginning  the  operation  whether  other  organs  besides  the  stomach  are 
injured  or  not,  it  is  incumbent  upon  the  surgeon  to  operate  on  all  cases, 
in  order  to  decrease  the  mortality  of  the  much  more  frequent  class  of 
injuries  from  nearly  loo  to  less  than  70  per  cent. — or,  if  we  accept 
Martin's  more  recent  figures,  to  as  low  as  25  per  cent. 

In  military  practice,  gunshot  wounds  of  the  stomach,  especially 
those  at  close  range,  are  almost  always  fatal.  No  operation  can  be 
undertaken  successfully  on  the  field  of  battle ;  Tufiier  quotes  the 
statement  made  to  him  by  a  Russian  surgeon  who  went  through  the 
entire  Russo-Japanese  campaign  :  not  one  patient  with  perforating 
gunshot  wound  of  the  abdomen,  treated  by  laparotomy,  recovered. 
By  the  time  such  patients  have  been  transferred  to  the  nearest  hos- 
pitals, they  are  either  already  dead,  or  peritonitis  is  so  far  advanced  as 
to  render  operation  unjustifiable. 

The  importance  of  early  operation  in  civil  life  may  be  seen  from 
the  following  figures,  copied  from  Forgue  and  Jeanbrau : 

I.  WOUNDS  OF  THE  STOMACH  ONLY. 

Mortality 
Cases.  Rec.  Died.  Per  Cent. 

Laparotomy  within  six  hours  of  injury 13  94  30 

Laparotomy  after  unknown  lapse  of  time.        6  2  4  66 

ig  II  8  42 

II.  WOUNDS  OF  OTHER  VISCERA  AS  WELL  AS  THE  STOMACH. 

Cases. 

Laparotomy  during  first  six  hours 29 

Laparotomy  during  second  six  hours. 13 

Lajjarotomy  after  lapse  of  twelve  hours. .      13 
Laparotomy  after  lap.sc  of  unknown  time.        8 

63  20  43  68 

Treatment.  The  bullet  wound  sliould  be  disinfected,  partial 
excision  of  its  margins  being  employed  if  necessary,  and  any  particles 
of  clothing  carried  into  the  wound  fas  in  President  McKinley's  case) 
should  be  removed.  Discarding  the  instruments  used  for  this  purpose, 
the  surgeon  should  open  the  abdomen  by  an  e])igastric  incision,  pass- 
ing through  the  left  rectus  muscle  close  lo  the  median  line.     Or  after 


Mortality 

Rec. 

Died. 

Per  Cent. 

13 

16 

55 

2 

II 

85  . 

2 

II 

85 

3 

5 

62 

Gunshot  Wounds  of  the  Stomach. 


323 


opening  its  sheath,  the  rectus  muscle  may  be  displaced  to  the  outer 
side,  and  the  abdomen  opened  without  separating  the  muscular  fibres. 
It  is  proper  to  follow  the  track  of  the  bullet  only  when  there  is  reason- 
able doubt  of  its  penetration.  A  very  oblique  impact  in  a  patient  with 
a  very  fat  abdominal  wall  may  result  in  the  bullet  making  a  non- 
penetrating wound  involving  only  the  abdominal  wall,  with  lodge- 
ment of  the  bullet  in  the  flank,  the  hypogastrium,  or  even  one  of  the 
thighs.  But  in  the  vast  majority  of  cases  there  will  be  no  doubt  of 
the  bullet's  penetration;  and  under  these  circumstances  a  median  in- 
cision gives  the  best  exposure.  The  "head  high "  (reversed  Trendelen- 
burg) posture,  with  a  sandbag  under  the  patient's  lower  dorsal  spine, 
is  a  great  help  in  exposing  the 
field  of  operation.  Intra- 
abdominal hemorrhage  must 
first  be  checked;  then  the 
search  for  perforations  is  be- 
gun. The  stomach  is  to  be 
located  immediately  beneath 
the  left  lobe  of  the  liver,  and 
as  soon  as  a  perforation  is 
found,  it  should  be  wiped 
clean,  and  inverted  with  at 
least  two  rows  of  Lembert 
sutures  of  fine  linen  thread. 
The    first  tier  may  be  in  the 

form  of  a  pursestring  suture.  It  is  not  advisable  to  search  for  other 
perforations  until  the  first  has  been  sutured.  If  a  wound  of  exit  can- 
not be  found  on  the  anterior  wall  of  the  stomach,  the  gastro-colic 
omentum  should  be  divided,  between  clamps,  and  below  (on  the  colic 
side  of)  the  gastro-epiploic  arteries,  for  a  distance  of  at  least  three  inches. 
A  free  abdominal  incision  and  a  free  opening  in  the  gastro-colic 
omentum  will  do  much  to  hasten  the  subsequent  steps  of  the  opera- 
tion. The  existence  of  a  perforation  in  the  posterior  wall  usually  will 
be  indicated  by  extravasation  within  the  lesser  peritoneal  cavity. 
Walton  Martin  states  that  among  the  cases  he  studied,  the  failure  to 
suture  the  bullet-hole  in  the  posterior  wall  of  the  stomach  had  not 


Fig.  33 


Wide  Opening  of  the  Gastro- 
colic Omentum  to  Explore  Poste- 
rior Gastric  Wall. 


324      Injuries  of  Diaphragm,  Stomach,  and  Duodenum. 

materially  influenced  the  mortahty.  Should,  however,  a  perforation 
be  detected  in  a  position  which  was  inaccessible  to  suture,  the  surgeon 
may  by  gastrotomy  (incising  the  anterior  wall  of  the  stomach)  evert 
the  posterior  wall  through  the  gastric  incision,  and  suture  the  posterior 
perforation  from  its  mucous  surface.  Sometimes  the  perforation  in 
the  anterior  wall  of  the  stomach  is  not  accessible  through  a  median 
wound.  This  is  most  frequently  the  case  when  the  perforation  is  at 
the  fundus  or  near  the  cardia.  Under  such  circumstances  it  is  best 
to  adopt  temporary  resection  of  the  costal  margin,  after  the  plan  ad- 
vocated by  Auvray.  In  this,  an  incision  is  made  from  the  upper  angle 
of  the  median  laparotomy  wound,  at  the  ensiform  process,  obliquely 
downward  to  the  tip  of  the  tenth  left  rib ;  this  incision  is  carried  down 
to  the  costal  cartilages,  and  these  are  then  divided,  from  their  sternal 
attachment  outward,  including  if  necessary  the  cartilage  of  the  tenth 
rib  itself.  If  care  be  exercised  to  keep  the  line  of  incision  in  the 
cartilages,  and  not  to  invade  the  osseous  structure  of  the  ribs,  the 
pleural  cavity  will  not  be  opened.  By  pulling  upward  on  the  costal 
border  thus  cut  loose,  the  tranversalis  muscle  and  the  diaphragm  may 
be  detached  from  the  internal  aspect  of  the  ribs,  and  then  in  order  to 
open  the  peritoneal  cavity  it  only  remains  to  divide  the  peritoneum 
and  the  transversalis  fascia  (Forgue  and  Jeanbrau).  The  little  extra 
time  occupied  in  making  this  section  is  fully  justified  by  the  free  ex- 
posure it  gives  of  the  fundus  of  the  stomach.  Should  the  diaphragm 
have  been  perforated  by  the  bullet,  it  would  probably  be  better  to 
approach  this  region  of  the  stomach  by  the  transpleural  route  (p. 
264).  Whenever  the  gunshot  wound  traverses  the  thorax  and  wounds 
the  abdominal  organs  the  question  will  arise  as  to  the  advisability  of 
draining  the  pleural  cavity.  Walton  Martin  advocates  drainage  of 
the  pleural  cavity  in  the  majority  of  such  cases;  and  we  are  inclined 
to  agree  with  him.  A  jjncumothorax  is  unavoidably  established  in 
such  cases  through  the  diaphragmatic  wound  as  soon  as  the  abdomen 
is  opened,  and  in  most  cases  it  probably  will  l)c  wise  to  drain  the 
pleural  cavity  from  the  outset  by  an  intercostal  incision. 

After  repairing  the  gastric  wounds,  search  must  be  made  for  other 
perforations,  in  the  colon,  the  duodenum,  and  neighbouring  coils  of 
small  intestine.     Wounds  of  the  liver  and  spleen,  and  sometimes  those 


Gunshot  Wounds  of  the  Stomach.  325 

of  the  pancreas,  owing  to  the  free  hemorrhage  which  usually  attends 
them,  will  probably  have  received  attention  even  before  those  of  the 
stomach. 

Usually  sufficient  drainage  of  the  lesser  peritoneal  cavity  can  be 
obtained  by  a  wick  of  gauze  carried  down  through  the  gastro-colic 
omentum.  In  rare  cases  it  is  advisable  to  make  drainage  through  the 
left  loin,  below,  or  even  above,  the  tip  of  the  twelfth  rib.  This  route 
has  been  particularly  studied  by  Mauclaire,  and  was  successfully 
employed  in  a  patient  recently  reported  to  the  Philadelphia  Academy 
of  Surgery  by  E.  B.  Hodge,  Jr.  In  very  few  cases  will  it  be  safe 
altogether  to  dispense  with  drainage  of  the  lesser  peritoneal  cavity. 
This  should  never  be  done  if  there  is  the  least  suspicion  of  injury  to 
the  pancreas. 

The  clamps  left  on  the  cut  margin  of  the  gastro-colic  omentum 
are  now  used  as  tractors,  drawing  the  colon  up  against  the  stomach; 
and  by  their  aid  the  incision  in  this  structure  may  be  repaired  by 
sutures  (which  also  serve  for  haemostasis),  except  where  the  drain 
emerges.  It  is  usually  safer  to  leave  another  drain  to  the  sutured 
area  on  the  anterior  gastric  wall;  and  as  many  more  gauze  packs  are 
to  be  inserted  as  may  be  necessary  to  localize  the  peritoneal  infec- 
tion. 

If  temporary  resection  of  the  costal  arch  have  been  employed,  it  will 
of  course  be  necessary  to  re-attach  the  diaphragm  to  the  lower  surface 
of  the  cartilaginous  flap,  and  to  restore  the  latter  to  its  place  by  the 
aid  of  deep  sutures  including  skin  and  intercostal  muscles. 

Forgue  and  Jeanbrau  point  out  that  suture  of  perforations  near 
one  of  the  gastric  orifices  may  cause  stenosis.  They  suggest  that,  in 
desperate  cases  with  pyloric  wound,  the  pyloric  perforation  might  be 
sutured  to  the  abdominal  wall  (temporary  pylorostomy).  A  formal 
pylorectomy  could  be  done  only  on  a  patient  whose  general  condition 
would  warrant  the  additional  time  and  shock  which  this  operation 
entails.  Gastrostomy  would  be  the  chief  resort  in  cases  where 
suture  of  a  perforation  near  the  cardiac  orifice  caused  occlusion  of  this 
opening. 


326      Injuries  of  Diaphragm,  Stomach,  and  Duodenum. 

REFERENCES. 

Borden:     Amer.  Practice    of   Surgery,  Ed.  by  Bryant    and    Buck,    New 

York,  1907,  iii,  652. 
Forgue  and  Jeanbrau:   Revue  de  Chir.,  1903,  xxviii,  285. 
Hodge:  Annals  of  Surgery,  190S,  i,  632. 
Martin:   Annals  of  Surgery,  1907,  i,  699. 
Mauclaire:   Revue  de  Chir.,  1902,  xxvi,  673. 
Tuffier:  Chirurgie  de  I'Estomac,  Paris,  1907,  p.  153. 

(C)  Rupture  of  the  Stomach.  This  may  be  either  the  so-called 
^^spontaneous'''  rupture,  or  the  iraitmaiic  variety. 

(i)  Under  the  name  spontaneous  rupture  of  the  stomach 
certain  cases  have  been  reported,  some  of  which  are  more  accurately 
described  as  ruptures  from  within  (pseudo-spontaneous  ruptures), 
since  they  were  clearly  due  to  the  trauma  inflicted  by  lavage.  Long 
ago,  Orth  recorded  a  fatal  gastric  hemorrhage  from  the  passage  of  a 
stomach  tube;  and  Key  Aborg  and  Strassmann  have  each  observed 
multiple  ruptures  of  the  gastric  mucosa,  as  the  result  of  too  forceful 
lavage  in  patients  dying  of  opium  poisoning.  In  another  patient  of 
Strassmann's,  with  gastric  cancer,  complete  rupture  of  the  gastric 
wall  was  produced  by  lavage,  and  at  autopsy  the  stomach  contents 
were  found  in  the  peritoneal  cavity.  In  a  patient  of  Wunscheim's 
a  carcinoma  of  the  oesophagus  ruptured  into  the  aorta  after  the 
passage  of  a  sound,  and  at  autopsy  there  were  also  found  rents  in  the 
mucous  coat  of  the  stomach.  Haberda  has  reported  a  fatal  case  of 
complete  rupture  of  the  stomach  due  to  its  artificial  distention  with 
air;  and  Ungar  observed  a  similarly  fatal  case  due  to  the  distention  of 
the  stomach  produced  by  swallowing  effervescent  powders. 

These  ruptures  from  over-distention  arc  more  frequent  along  the 
lesser  curvature,  radiating  from  the  cardia.  They  have  been  par- 
ticularly studied  by  Key  Al)org  and  ])\  I-'raenckcl,  each  of  whom  con- 
ducted experiments  to  test  the  elasticity  of  the  stomach,  and  its  most 
frequent  site  of  rupture.  With  a  view  to  preventing  rupture,  it  is  above 
all  things  important  to  ])erf()rm  lavage  with  gentleness,  and  at  leisure; 
especially  is  this  the  case  with  patients  whose  stomachs  are  known  to 
be  .seriously  diseased,  and  in  those  who  are  unconscious,  since  the 


Rupture  of  the  Stomach.  327 

sensations  of  the  patient  form  a  very  valuable  guide  to  the  quantity 
of  fluid  which  may  safely  be  introduced  into  the  stomach. 

True  spontaneous  ruptures  appear  to  have  been  recorded  in  at 
least  nine  instances.  Abstracts  of  these  cases  follow,  the  first  seven 
references  being  quoted  from  the  well  known  paper  on  injuries  of  the 
stomach  by  Petry : 

1.  Brush.     Sudden  pain  and  collapse  during  effort  to  lift  a  stone; 

slow  recovery  without  operation.  For  forty  years  suiTered  from 
gastric  troubles.  At  autopsy  there  was  found  a  gastro-pan- 
creatico-duodenal  fistula;  the  pylorus  was  tightly  stenosed. 
This  case  appears  rather  apocryphal  in  the  light  of  modern 
knowledge. 

2.  Newman.     Insane  patient;    during  violent  vomiting  after  meal, 

developed  pain,  collapse,  tympany,  subcutaneous  emphysema. 
Rupture  of  entire  gastric  wall  found  at  autopsy. 

3.  Revilliod.     Spontaneous    rupture    from   fermentative    distention. 

Autopsy  showed  no  ulcer;  two  ruptures  in  serous  coat. 

4.  Hoffman.     Spontaneous    rupture    from    fermentative    distention. 

Death. 

5.  Thompson.     Spontaneous  rupture  from  unknown  cause.     No  in- 

jury. 

6.  Lantschner.     Stomach  in  umbilical  hernia.     After  drinking  im- 

mense quantity  of  water  and  tea,  rupture  caused  by  vomiting. 
Died. 

7.  Chiari.     Spontaneous  rupture  from  fermentative  distention.     Au- 

topsy showed  longitudinal  rupture  in  scar  of  old  ulcer. 

8.  Ipsen.     Spontaneous  rupture  from  vomiting.     Death. 

9.  Wilke.     Autopsy  on  patient  with  volvulus  of  stomach,  showed 

rupture  of  its  posterior  wall  causing  death  from  peritonitis. 

As  pointed  out  by  Doujon,  it  is  quite  probable  that  some  form  of 
gastric  volvulus,  self  reduced  before  death,  or  undiscovered  at  autopsy, 
is  the  chief  cause  of  such  spontaneous  ruptures  in  apparently  healthy 
stomachs;  and  the  case  since  reported  by  Wilke,  and  above  quoted, 
supports  this  view.  Strassmann  suggests  that  these  mucous  lacera- 
tions may  be  much  more  frequent  than  is  generally  appreciated,  and 
questions  whether  they  may  not  form  the  initial  stage  of  gastric  ulcer 
or  carcinoma.  As  already  mentioned,  other  writers  seem  to  have 
had  the  same  idea.     (See  p.  70.) 


328      Injuries  of  Diaphragm,  Stomach,  and  Duodenum. 

According  to  Rehn,  spontaneous  rupture  from  gaseous  distention 
is  not  very  rare  in  horses,  but  generally  is  observed  along  the  greater 
curvature. 

Gastric  hemorrhages,  possibly  due  to  ruptures  of  the  mucosa, 
have  been  observed  in  patients  who  have  fallen  on  the  back,  on  the 
buttocks,  and  even  in  one  injured  by  a  "general  shaking  up."  (Strass- 
mann,  loc.  cit.,  S.  166.) 

REFERENCES. 
Aborg:   See  Key  Aborg. 

Brush:   N.  Y.  Med.  Record,  1885,  xxvii,  623. 

Chiari:   Wien.  med.  Blatter,  No.  3;   in  Virchow-Hirsch,  1881,  ii,  177. 
Doujon:   Gaz.  Med.  de  Paris,  1903,  Ixxiv,  182. 
Fraenckel:  Deutsch.  Arch.  f.  klin.  Med.,  1907,  Ixxxix,  113. 
Haberda:  Vierteljahrsschr.  f.  gerichtl.  Med.,  1907,  xxxiii,  Suppl.,  S.  169. 
Hoffman:   Anzeiger  d.  Ges.  d.  Aerzte  in  Wien.,  1881,  ii,  178. 
Ipsen:  Vierteljahrsschr.  f.  gerichtl.  Med.,  1907,  xxxiii,  Suppl.,  S.  170. 
Key  Aborg:  Vierteljahrsschr.  f.  gerichtl.  Med.,  1891,  iii  F.,  S.  42. 
Lantschner:  Wien.  med.  Blatter.,  No.  3;    in  Virchow-Hirsch,  i88t,  ii,  177. 
Newman:   Cited  by  Petry,  loc.  infra  cit.      (The  only  reference  given  by 

Petry  is  "Lancet,  Dec.  5.") 
Orth:  Cited  by  Strassmann,  loc.  infra  cit. 
Petry:   Beitr.  z.  klin.  Chir.,  1896,  xvi,  545;   595. 
Rehn:   Arch.  f.  klin.  Chir.,  1896,  liii,  383. 
Reviiliod:   Cited  by  Petry,  loc.  supra  cit. 

Strassmann:  Vierteljahrsschr.  f.  gerichtl.  Med.,  1907,  xxxiii,  Suppl.,  S.  143. 
Thompson:   London  Med.  Gazette,  1842,  xli,  34. 

Ungar:   Vierteljahrsschr.  f.  gerichtl.  Med.,  1907,  xxxiii,  Suppl.,  S.  169. 
Wilke:   Miinch.  med.  Woch.,  1907,  liv,  1012. 
Wunscheim:    Cited   by   Fraenckel:    Deutsch.   Arch.   f.   klin    Med.,  1907, 

Ixxxix,  113. 

(2)  Traumatic  Rupture  of  the  Stomach.  This  is  usually 
accompanied  by  such  extensive  visceral  injuries  as  to  terminate  fatally 
before  surgical  treatment  can  be  instituted.  Geill  in  eight  and  a  half 
years  found  35  ruptures  of  the  stomach  at  autopsy  in  Vienna,  and 
Strassmann  obiserved  about  the  same  number  at  autopjsies  in  Berlin, 
during  about  fifteen  years.  One  such  case  has  been  observed  at  the 
Episcopal  Hospital,  lMiiIadcl])hia  (1901).  But  as  an  Injury  which 
interests  surgeons  it  must  be  considered  rare. 

The  causes  are  blows,  falls,  and  crushes,  especially  the  last. 
Kicks  by  horses  arc  also  a  frequent  cause. 


Rupture  of  the  Stomach.  329 

Rehn  divides  ruptures  of  the  stomach  into  (i)  those  involving  only 
the  serous  coat;    (2)  those  affecting  the  serous  and  muscular  coats; 

(3)  interstitial  ruptures,   including  submucous   haematomata,   etc.; 

(4)  ruptures  of  the  mucosa;  (5)  penetrating  ruptures — those  in  which 
the  entire  thickness  of  the  gastric  wall  is  involved.  From  the  ex- 
periments conducted  by  Fraenckel  and  others,  it  appears  that  mucous 
ruptures  are  usually  produced  by  overdistention  from  within;  that 
ruptures  of  the  serous  coat  alone  are  frequently  the  result  of  external 
pressure  on  a  distended  stomach;  that  contusions  result  in  inter- 
stitial ruptures ;  and  that  complete  ruptures  are  more  apt  to  be  caused 
by  crushing  of  the  stomach  against  the  spinal  column. 

Petry  in  his  study  of  subcutaneous  ruptures  of  the  alimentary 
canal,  found  the  stomach  involved  in  21  cases,  the  small  bowel  in 
172  (of  which  9  were  duodenal  ruptures),  and  the  large  bowel  in  26 
cases.  Of  the  21  gastric  ruptures,  eight  he  termed  spontaneous,  in- 
cluding here  the  case  reported  by  Key  Aborg  (which  we  have  classed 
as  pseudo-spontaneous).  These  cases  have  already  been  discussed 
(p.  326).  Of  the  13  traumatic  ruptures,  two  were  submitted  to  opera- 
tion; death  quickly  ensued  in  five  of  the  remaining  patients  (11  in 
number),  on  whom  no  operation  was  done.  Of  the  six  unoperated 
patients,  who  survived,  two  recovered  with  gastro-cutaneous  fistulae, 
two  were  operated  on  after  4  and  2  weeks  respectively,  for  perigastric 
abscesses,  but  eventually  recovered;  while  in  the  remaining  two  pa- 
tients, traumatic  ulcers  formed,  which  subsequently  necessitated 
further  treatment.  Tawastsjerna  collected  in  1905,  125  cases  of 
operation  for  subcutaneous  rupture  of  the  abdominal  viscera,  all  that 
had  been  recorded  since  the  pubhcation  of  the  paper  by  Petry,  men- 
tioned above.  Of  these  more  recent  cases,  41  recovered,  and  84  died, 
a  death  rate  of  67.2  per  cent.  Meerwein  in  1907  studied  93  operations 
for  subcutaneous  rupture  of  the  abdominal  viscera,  recorded  since 
1896.  He  found  that  among  69  patients  operated  on  within  24  hours 
of  the  injury,  38  died,  a  mortality  of  55.1  per  cent.;  while  of  24  pa- 
tients who  were  not  operated  on  until  more  than  24  hours  had  elapsed, 
no  less  than  14  died,  a  mortality  of  66.7  per  cent.  Although  these 
figures  probably  are  relatively  correct,  in  that  they  show  the  value  of 
early  operation  as  a  life  saving  measure,  there  is  also  no  doubt  that, 


330      Iniuries  of  Diaphragm,  Stomach,  and  Duodenum. 

as  Meerwein  points  out,  these  results  are  much  more  favourable  than 
are  actually  obtained  in  any  consecutive  series  of  cases.  To  support 
this  assertion,  Meerwein  quotes  the  following  series  of  operations  for 
rupture  of  the  abdominal  viscera. 

Mortality 
Authority.  No.  of  Operations.     Recovered.  Died.  Per  Cent. 

Neumann 21  i  20  95.2 

Schmitt 716  85.7 

Voswinckel 14  2  12  85.7 

Hagen 17  i  16  94.1 

Thommen 17  2  15  88.2 

Basel  clinique 18  3  15  83.3 

Hildebrand 12  5  7  58.3 

106  15  91  85.8 

It  should  be  noted  that  the  cases  reported  by  Hildebrand  have  all  been 
treated  within  recent  years. 

Only  four  operations  for  traumatic  rupture  of  the  stomach  appear 
to  have  been  recorded.  The  patient  of  Mikuhcz  had  been  drinking 
heavily,  and  was  taken  with  sudden  abdominal  pain,  followed  by 
extreme  tympany  and  collapse.  Mikulicz  first  punctured  the  ab- 
domen ;  the  gas  which  escaped  was  inflammable,  and  smelled  strongly 
of  alcohol.  By  laparotomy  a  rupture  of  the  lesser  curvature  was 
sutured,  but  the  patient  died  three  hours  later.  Although  the  stomach 
evidently  was  diseased  prior  to  the  time  of  rupture,  it  was  the  opinion 
of  Mikulicz  that  the  rupture  was  traumatic  in  origin,  due  either  to 
distention  from  within  the  stomach  or  to  unrecorded  external  injury. 
Rehn's  patient  fell  from  a  second  story  window,  but  recovered  after 
prompt  suture  of  the  rent  in  the  stomach.  Only  two  other  operations 
for  this  condition  appear  to  have  been  recorded  (Thommen  and 
Korte).  Although  both  patients  died,  Thommen's  lived  four  days, 
and  death  was  found  at  auto])sy  to  be  due  to  a  ru])ture  of  the  duo- 
denum undiscovered  when  the  rupture  of  the  stomach  was  sutured. 

Interstitial  ruptures  of  the  stomach  may  cause  (i)  Haematoma; 
(2)  Cyst;  (3)  Abscess.  This  subject  has  been  recently  the  subject 
of  an  interesting  monograi)h  by  I3r.  Pedro  Chulro,  of  Ikicnos  Aires, 
and  it  is  from  his  work  that  most  of  what  follows  has  been  abstracted. 
Rupture  of  a  vessel  in  the  suljmucosa  is  possiljly  the  first  lesion;  and 
the  haemat(^ma  wlu'cli   forms   may  Ijc  grachially  absorbed,  without 


Rupture  of  the  Stomach.  331 

producing  very  acute  symptoms.  If  of  large  size,  however,  a  cyst 
will  form,  and  usually  this  cyst  becomes  more  or  less  infected  from 
transudation  through  the  mucous  membrane  which  forms  one  of  its 
walls.  A  certain  amount  of  gastric  juice  may  be  secreted  directly 
into  the  cyst,  from  the  deep  layer  of  the  mucosa.  By  some  such 
process  as  this  there  is  formed  an  abscess,  which  in  the  patient  on  whom 
Chutro  operated  resembled  a  cold  abscess  in  character.  Zeigler  op- 
erated on  a  patient  who  had  received  an  abdominal  injury  some  weeks 
previously;  he  found  a  large  haematoma  in  the  anterior  wall  of  the 
stomach;  recovery  was  uneventful.  Similar  cases,  without,  however, 
a  history  of  injury,  have  been  recorded  by  Sloane  and  Anderson. 
Sloane's  patient  died  from  typhoid  fever,  and  the  gastric  condition 
was  not  suspected  during  life.  Anderson's  patient  died  after  the 
hasmatoma  had  been  drained  by  laparotomy.  Rendu  operated  on  a 
patient  with  an  infected  cyst  of  the  gastric  wall;  death  occurred  from 
peritonitis.  Gallois,  Houlong  and  Leflaive  recorded  a  case  where 
death  was  due  to  rupture  of  a  cyst  of  the  posterior  wall  of  the  stomach. 
Chutro's  own  patient,  a  boy  of  9  years,  received  a  kick  from  a  horse 
in  the  epigastric  region;  19  days  later  an  interstitial  abscess  in  the 
posterior  gastric  wall  was  opened  and  drained  by  laparotomy;  un- 
eventful recovery  ensued.  Although  a  history  of  injury  is  certain  in 
only  the  patients  of  Zeigler  and  Chutro,  it  seems  proper  to  mention 
the  others  in  this  place,  in  view  of  what  we  have  already  learned  of  the 
character  of  mucous  and  spontaneous  ruptures  of  the  stomach. 

Menne  has  recently  made  an  extensive  study  of  the  after  effects 
of  injuries  of  the  stomach.  He  collected  51  cases  in  which  lesions 
of  the  gastric  mucosa  (ulcer,  stenosis,  etc.)  followed  trauma,  45  being 
due  to  direct,  and  5  to  indirect  violence,  while  in  one  case  the  nature 
of  the  injury  was  not  stated.  In  24  cases  the  injury  was  produced  by 
moving  bodies  impinging  upon  the  patient's  abdomen,  and  in  27 
cases  it  was  caused  by  the  collision  of  the  patient  with  bodies  at  rest. 
He  further  tabulates  8  cases  of  gastric  hemorrhage  or  perforation  due 
to  more  or  less  indirect  injuries,  such  as  muscular  efforts,  etc. 

Rupture  of  Right  Gastro-Epiploic  Artery.  An  isolated  case 
of  this  nature,  accompanied  by  an  insignificant  tear  in  the  margin  of 


332      Injuries  of  Diaphragm,  Stomach,  and  Duodenum. 

the  hvcr,  due  to  the  kick  of  a  horse,  has  been  recorded  by  Vatter. 
Laparotomy  was  done  on  account  of  symptoms  of  internal  hemorrhage; 
the  artery  was  hgated,  and  recovery  ensued. 

OPERATIONS  FOR  RUPTURE  OF  THE  STOMACH. 

MikuHcz.     Died  in  3  hours. 
Rehn.     Died  in  4  days. 
Korte.     Died  same  night. 

Thommen.     Died  4  days  later  from  peritonitis  due  to  undiscovered 
rupture  of  descending  portion  of  duodenum. 

REFERENCES. 

Chutro:   Revista  de  la  Soc.  Med.  Argentina,  1905,  xiii,  171. 

Fraenckel:   Deutsch.  Arch.  f.  klin.  Med.,  1907,  Ixxxix,  113. 

Geill:   Cited  by  Strassmann,  loc.  infra  cit. 

Korte:   See  Voswinckel,  Arch.  f.  klin.  Chir.,  1906,  Ixxix,  490. 

Meerwein:   Beitr.  z.  klin.  Chir.,  1907,  liii,  496. 

Menne:  Arch.  f.  klin.  Orthop.,  1905-6,  iv,  i. 

Mikulicz:   Volkmann's  Samml.  khn.  Vortrage,  1885,  No.  262. 

Petry:   Beitr.  z.  klin.  Chir.,  1896,  xvi,  545;   595. 

Rehn:  Arch.  f.  klin.  Chir.,  1896,  liii,  383. 

Strassmann:  Vierteljahrsschr.  f .  gerichtl.  Med.,  1907,  xxxiii,  SuppL,  S.  143. 

Tawastjerna:  Cited  by  Voswinckel,  Arch.  f.  klin.  Chir.,  1906,  Ixxix,  490. 

Thommen:   Arch.  f.  klin.  Chir.,  1902,  Ixvi,  574.     Fall  34. 

Vatter:   Zentralbl.  f.  Chir.,  1904,  xxxi,  1252. 

fD)  Foreign  Bodies  in  the  Stomach.  Children,  insane  people, 
and  mountebanks  form  the  chief  classes  of  patients  to  be  considered 
here.  Others  by  mistake  occasionally  swallow  a  tooth-plate,  a  piece 
of  bone,  or  some  similar  object.  Children  most  frequently  swallow 
coins,  buttons,  pins,  etc.  The  insane  swallow  almost  everything; 
hair  swallowing  is  done  only  by  those  with  neurotic  taint,  frequently 
during  convalescence  from  some  debilitating  disease,  such  as  tyj^hoid 
fever.  Sword  swallowcrs  occasionally  try  to  exhibit  tlieir  art  with 
too  short  a  knife;  it  may  slip  from  their  grasj)  and  be  hurried  into  the 
stomach  by  involuntary  efforts  at  swallowing.  Pieces  of  glass,  nails, 
and  all  manner  of  articles  are  sometimes  swallowed  by  showmen. 

The  majority  of  such  articles  as  pass  through  the  straits  of  the 
oesophagus  and  reach  the  stomach  without  difficulty  will  also  pass  the 
pylorus,  traverse  the  intestinal  tract,  and  be  discharged  from  the  anus 


Foreign  Bodies  in  the  Stomach.  333 

in  the  course  of  a  few  days  without  producing  any  symptoms.  The 
form,  consistency,  and  bulk  of  the  article  swallowed,  are,  in  the  order 
mentioned,  the  characters  which  have  most  influence  on  the  prognosis. 
Bodies  of  rounded  form,  such  as  coins,  or  at  least  those  which  have  no 
prongs  or  sharp  angles,  will  usually  pass  without  trouble.  Certain 
other  articles,  such  as  pieces  of  bone,  may  become  partially  digested 
in  the  stomach,  and  may  thus,  with  their  sharp  angles  rounded  off,  be 
discharged  without  causing  injury  to  the  gastro-intestinal  tract.  As 
far  as  the  stomach  is  concerned,  the  size  of  the  body  swallowed  is  the 
least  important  factor  in  the  prognosis,  as  it  is  almost  certain  that 
articles  which  can  pass  the  cardiac  orifice  can  also  pass  the  pylorus. 
This  remark,  however,  does  not  apply  to  long  nails,  slate-pencils,  knives 
and  forks,  in  which  form  is  of  greater  importance  than  mere  bulk. 

Occasionally,  as  in  children  and  in  the  insane,  no  history  of 
swallowing  a  foreign  body  can  be  obtained.  Apart  from  such  a 
history,  the  symptoms  of  the  lodgement  of  a  foreign  body  in  the 
stomach  are  chiefly  those  of  pain  and  vomiting.  The  latter  may  be 
persistent,  and  the  vomitus  may  be  streaked  with  blood.  In  other 
cases,  in  spite  of  pain,  no  nausea  is  present,  and  appetite  may  even 
be  preserved. 

The  diagnosis  in  acute  cases  is  rarely  difficult,  because  of  the 
history.  But  it  is  frequently  difficult  to  determine  the  presence  of 
hair  tumors  (QEgagropile,  Trichobezoar)  before  operation,  because  the 
patient  either  is  not  aware  that  she  has  been  in  the  habit  of  swallowing 
her  hair,  or  she  is  unwilHng  to  acknowledge  the  habit.  In  the  insane 
the  diagnosis  may  be  impossible  without  the  aid  of  the  Roentgen  rays. 

If  the  foreign  body  remain  in  the  stomach,  it  may  be  quiescent  for 
long  periods;  it  may,  on  the  other  hand,  cause  ulceration,  perigas- 
tritis, subacute  perforation,  and  finally  a  subcutaneous  abscess;  in 
rare  instances  it  may  directly  perforate  the  gastric  wall.  At  least  one 
instance  (English)  of  perforation  of  the  duodenum  by  a  foreign  body 
is  on  record.  The  patient  was  saved  by  operation.  In  a  case  re- 
corded by  Lucas,  a  nail  which,  as  shown  by  skiagraphs,  had  been 
lodged  for  some  weeks  in  the  descending  duodenum,  was  successfully 
removed  by  duodenotomy.  Chaput  also  has  removed  by  enterot- 
omy  a  foreign  body  impacted  in  the  duodenum. 


334      Injuries  of  Diaphragm,  Stomach,  and  Duodenum. 

The  trcaimoit  to  be  adopted  depends  on  the  nature  of  the  body 
swallowed.  If  certain  to  pass,  the  Vienna  treatment,  advocated  long 
ago  by  Billroth,  should  be  employed.  This  consists  of  a  diet  of 
mashed  potatoes,  or  such  similar  substances  as  will  tend  to  coat  the 
foreign  body  and  aid  its  passage  through  the  intestinal  tract.  When 
once  out  of  the  stomach,  it  is  most  apt  to  be  arrested  at  some  point  in 
the  lower  ileum.  Under  no  circumstances  should  a  purge  be  given. 
The  violent  peristalsis  thus  aroused  is  much  more  likely  to  cause 
perforation  of  the  stomach  or  bowel,  or  intestinal  obstruction  from 
inflammatory  oedema,  than  to  promote  the  passage  of  the  foreign 
body  through  the  intestinal  tract.  If  no  symptoms  are  produced  by 
the  swallowed  article,  there  need  be  no  haste  in  resorting  to  operation, 
even  if  it  is  manifestly  impossible  for  the  foreign  body  to  escape  from 
the  stomach.  The  Roentgen  rays  may  be  employed,  and  the  location 
of  the  oft'ending  substance  determined.  As  its  weight  may  cause  the 
stomach  to  descend  much  below  its  normal  position,  it  may  appear  that 
the  foreign  body  is  in  the  large  bowel  (especially  the  Ccecum)  instead 
of  in  the  stomach.  The  passage  of  a  stomach  tube,  or  the  intro- 
duction of  bismuth  emulsion  into  the  stomach  just  before  a  second 
skiagraph  is  made,  probably  will  determine  the  question. 

Gastrotomy  is  indicated  (i)  when  it  is  clearly  impossible  for  a 
quiescent  foreign  body  to  be  discharged  spontaneously;  (2)  when  any 
symptoms  arise  from  any  variety  of  foreign  body;  (3)  it  is  occasionally 
required  for  the  removal  of  a  foreign  body  impacted  in  the  lower  end  of 
the  oesophagus.  The  use  of  endogastric  instruments,  as  employed  by 
Chevalier  of  Pittsburgh,  is  justifiable  only  in  the  hands  of  a  specialist. 
The  average  surgeon  will  consult  his  patient's  safety  much  more  by 
resorting  to  gastrotomy. 

This  operation,  for  this  purpose,  is  said  to  have  been  Jh-st  done  by 
Daniel  Schwabe  in  1635.  His  patient,  operated  on  without  an  an- 
aesthetic, recovered.  It  was  not  until  1848  that  the  operation  was 
repeated,  by  Tilanus.  In  1887  Bcrnays  collected  11  cases  of  gastro- 
tomy for  foreign  bodies,  including  one  of  his  own;  he  also  referred  to 
16  other  o])eralions  wliich  consisted  in  extracting  foreign  bodies  from 
the  stomach  after  tliis  \iscus  had  Ijecome  adherent  to  the  i)arictal 
peritoneum  as  the  result  of  perigastritis  set  up  by  the  foreign  body. 


Foreign  Bodies  in  the  Stomach.  335 

Of  the  II  patients  in  the  former  series,  only  2  died.  The  late  Prof. 
Ashhurst  refers  to  50  cases  of  gastrotomy  for  the  extraction  of  foreign 
bodies,  42  of  which  terminated  in  recovery.  He  says  that  "foreign 
bodies  which  have  been  swallowed,  and  having  ulcerated  through  the 
walls  of  the  stomach,  had  lodged  in  various  parts  of  the  abdominal 
cavity,  have  been  successfuUy  removed  by  LeDentu,  Bardeleben  (two 
cases),  Nussbaum  (two  cases),  LeFilher,  and  Dubois." 

Among  20  recent  cases  of  gastrotomy  for  foreign  body,  references 
to  which  are  appended,  there  was  only  i  death,  a  mortality  of  5  per 
cent.  Two  patients  (professional  "sword-swallowers")  whose  cases 
are  recorded  by  Revenstorf  and  Warbasse,  were  operated  on  twice, 
both  times  successfully. 

The  operation  consists  (i)  in  opening  the  abdomen  through  the 
left  rectus  muscle,  or  in  passing  to  the  median  side  of  this  muscle  after 
opening  its  sheath;  (2)  in  locating  the  stomach;  (3)  in  drawing  the 
stomach  into  the  wound,  and  isolating  it  by  gauze  packs ;  (4)  opening 
the  stomach,  preferably  by  an  incision  transverse  to  its  long  axis,  so  as 
not  to  divide  the  circular  muscle  fibres;  (5)  removing  the  foreign  body 
by  forceps  or  fingers;  (6)  suturing  the  gastric  incision  with  at  least 
two  rows  of  Lembert  sutures,  or  one  of  the  Czerny  and  one  of  the 
Lembert  type;    (7)  closing  the  abdominal  wound. 

The  incision  in  the  stomach  should  be  no  longer  than  is  absolutely 
requisite  for  the  extraction  of  the  foreign  body.  It  is  well  to  locate  the 
body  and  fix  it  against  a  convenient  portion  of  the  gastric  wall  before 
opening  the  stomach.  Should  it  be  impossible  to  remove  a  body  im- 
pacted in  the  lower  oesophagus,  gastrostomy  should  be  performed; 
this  procedure  was  necessary  in  a  patient  under  Jacobson's  care 
in  1889;  unfortunately  the  patient  did  not  survive  more  than  two  days. 
In  a  similar  case  recorded  in  1900  by  Edmunds  a  tooth-plate  was  suc- 
cessfully removed  from  the  lower  oesophagus  by  gastrotomy. 

RECENT  CASES  OF  GASTROTOMY  FOR  FOREIGN  BODY. 

I.  For  nails,  pins,  spoons,  keys,  etc. 

Benjamin:   Annals  of  Surgery,  1907,  xlv,  238.     Recovered. 
Chenieux:    Bull,  et  Mem.  de  la  Soc.  de  Chir.  Paris,   1905, 
xxxi,  517.     Recovered. 


336      Injuries  of  Diaphragm,  Stomach,  and  Duodenum. 

Godineau:    Bull,  et   Mem.  de  la  Soc.  de  Chir.  Paris,  1905, 

xxxi,  450.     Recovered. 
Holding:  Annals  of  Surgery,  1904,  xl,  354.     Recovered. 
Lowry:   Lancet,  1905,  ii,  1107.     Recovered. 
Monnier:  Bull.  Aled.  de  Quebec,  1903-4,  v,  170.     Recovered. 
Revenstorf  and  Lauenstein:   Miinch.  med.  Woch,  1906,  liii,  i, 

1232.     Recovered. 
Revenstorf:   Ibid.     Recovered. 

Warbasse:  Annals  of  Surgery,  1904,  ii,  909.     Recovered. 
Warbasse :   Ibid.     Recovered. 

II.  For  Hair-balls. 

Dandois:  Bull.  Acad.  Roy.  de  Med.  de  Beige,  1903,  4e.  s.,  xvii, 
103 1.     Recovered. 

Ilderton  and  Thorburn:  Brit.  Med.  Jour.,  1907,  i,  18.  Re- 
covered. 

Juvara:  Bull.  Soc.  med.  et  nat.  de  Jassy,  1904,  xviii,  58. 
Recovered. 

Harvie:   Jour.  Amer.  Med.  Assoc,  1908,  i,   512.     Recovered. 

III.  For  mass  of  wood-fibres,  from  chewing  licorice  sticks,  etc. 

Werder:  Trans.  Amer.  Assoc.  Obst.  and  Gyn.,  N.  Y.  (1903), 
1904,  xvi,  140.     Recovered. 

IV.  For  False  teeth. 

Friedrich:  Deutsch.  med.  Woch.,  1904,  xxx,  526.     Recovered. 

V.  For  bodies  impacted  in  lower  QEsophagus. 

Billot  and  Delporte:   Arch,  de  Med.  et  Pharm.  Miht.,  1906, 

xlviii,  500.     Recovered. 
Edmunds:   Brit.  Med.  Jour.,  1900,  ii,  1438. 

VI.  Subcutaneous  Abscess,  connecting  with  cavity  of  Stomach. 

Lejars:   Bull,  et  Mem.  de  la  Soc.  de  Chir.  Paris,  1906,  xxxii, 

1 122.     Recovered. 
McLcod:    Practitioner,  1905,  Ixxv,  349.     Died  of  exhaustion 

in  6  days. 

REFERENCES. 

Ashhurst,  J.,  Jr.:    Principles  and   Practice  of  Surgery,  6th  Ed.,  Phila., 

1893,  p.  426. 
Bernays:   Med.  Brief,  St.  Louis,  1907,  xxxv,  524. 
Chaput:   Bull,  et  Mem.  Soc.  Chir.  Paris,  1907,  xxxiii,  12 17. 
English:  Lancet,  1905,  ii,  1545. 

Jacobson  and  Rowlands:  The  Operations  of  Surgery,  Phila.,  1908,  ii,  460 
Lucas:  Report  of  Soc.  Study  Dis.  Children,  London  (1900)  1901,  i,  213. 
Schwabe:   Cited  in  Berl.  klin.  Woch.,  1883,  xx,  106. 


Injuries  of  the  Duodenum.  337 

III.  Injuries  of  the  Duodenum. — Injuries  of  the  first  portion  of 
the  intestinal  tract  differ  from  those  of  other  portions  chiefly  on  ac- 
count of  the  situation  of  the  duodenum;  not  only  is  it  in  close  relation 
with  other  structures  of  the  greatest  importance  (superior  mesenteric 
vessels,  portal  vein,  pancreas,  etc.),  but  it  also  is  quite  firmly  fixed  on 
account  of  its  retro-peritoneal  position.  Wounds  of  the  duodenum, 
therefore,  are  more  frequently  complicated,  as  well  as  more  difficult 
to  treat,  than  are  those  of  the  jejunum  or  the  ileum. 

(A)  Stabwounds  of  the  duodenum,  unaccompanied  by  more 
serious  lesions,  do  not  appear  to  have  been  observed.  It  is  of  course 
conceivable  that  such  an  isolated  wound  might  occur,  either  through 
the  loin,  or  from  in  front,  grazing  the  liver  and  the  colon,  or  even  by 
passing  through  the  gastro-colic  omentum,  and  reaching  the  trans- 
verse duodenum. 

(B)  Gunshot  wounds  of  the  duodenum,  unaccompanied  by  more 
serious  injuries,  have  been  observed  in  several  instances.  xA^ccording 
to  Cackovic,  a  gunshot  wound  of  the  duodenum  was  first  sutured  by 
Ramsay,  in  1885.  Harte  reported  a  patient  with  a  "grooved"  wound 
of  the  first  portion  of  the  duodenum,  and  perinephric  hemorrhage, 
who  recovered  after  suture  of  the  perforation  of  the  duodenum  by 
laparotomy,  and  arrest  of  the  hemorrhage  by  packing  the  kidney 
region  through  the  loin.  Summers  operated  on  a  patient  who  had 
been  shot  in  the  right  loin.  A  double  perforation  of  the  duodenum 
was  found,  also  a  perforation  of  the  gall  bladder.  The  latter  injury, 
and  the  anterior  perforation  of  the  duodenum  were  repaired,  by 
sutures,  by  laparotomy;  and  the  posterior  (retro-peritoneal)  perfora- 
tion of  the  duodenum,  and  a  wound  of  the  kidney,  were  tamponned 
through  a  lumbar  incision.  Death  occurred  in  three  days  from 
"retro-peritoneal  phlegmon,"  not  from  peritonitis. 

The  treatment  of  gunshot  wounds  of  the  duodenum  is  difficult  be- 
cause of  their  deep  situation,  and  the  frequency  with  which  retro- 
peritoneal injuries  are  overlooked.  Modern  experience  wath  mobil- 
ization of  the  duodenum  will  render  access  to  retro-peritoneal  lesions 
of  its  descending  portion  less  difficult  than  heretofore.  But  the  un- 
certainty which  always  exists  as  to  the  efficiency  of  closure  of  retro- 


^^^      Injuries  of  Diaphragm,  Stomach,  and  Duodenum. 

peritoneal  portions  of  the  intestine,  makes  the  prognosis  in  such  cases 
particularly  grave.  It  usually  will  be  well  to  drain  the  sutured  area, 
particularly  if  it  be  retro-peritoneal.  Drainage  should  always  be 
employed,  preferably  through  the  loin,  if  a  retro-peritoneal  perfora- 
tion is  suspected  but  not  definitely  located;  or  if  one  is  located  in  an 
inaccessible  place.  Resection,  with  end-to-end  anastomosis  may 
sometimes  be  required.  In  many  instances  it  probably  will  be  safer 
to  close  both  ends  of  the  duodenum,  and  restore  the  continuity  of  the 
intestinal  canal  by  some  form  or  forms  of  lateral  anastomosis,  as  in 
the  case  of  Meerwein  to  be  quoted  below. 

(C)  Rupture  of  the  Duodenum.  Because  of  its  fixed  position 
against  the  spinal  column,  rupture  of  the  duodenum  is  by  no  means  so 
imusual  as  might  be  supposed.  Meerwein  has  recently  collected  64 
cases;  and  he  refers  to  18  others  included  in  the  tables  previously 
published  by  Jeannel,  the  original  references  to  which  were  not  ac- 
cessible to  him.  According  to  Cackovic,  operation  for  rupture  of  the 
duodenum  was  first  done  in  1896  by  Herczel.  To  show  the  relative 
frequency  Avith  which  the  duodenum  is  ruptured,  the  following  figures 
are  quoted  from  Gage:  Duodenum,  10  cases;  jejunum,  20  cases; 
ileum,  42  cases;  colon,  6  cases.  Meerwein  studied  the  records  of  28 
operations  for  this  condition:  16  patients  recovered,  and  12  died,  a 
mortality  of  42.85  per  cent.  But  in  6  of  the  fatal  cases  the  rupture  in 
the  duodenum  was  not  found;  so  that  the  mortality  attending  the 
completed  operations  is  only  27.27  per  cent.  Of  the  six  fatal  cases 
in  which  the  rupture  was  found  at  the  time  of  operation,  three  patients 
died  at  once,  two  died  later  from  peritonitis,  and  one  patient  (Moyni- 
han's)  lived  in  excellent  health  for  104  days  after  the  operation,  and 
died  then  from  perforation  of  the  intestine  by  the  Murphy  button 
which  har]  been  employed  at  the  operation.  Sherwood  lias  recorded  a 
case  of  rupture  of  the  duodenum,  which  is  not  included  in  Meerwein's 
statistics.  This  jjatient  died  seven  days  after  suture  of  the  rupture, 
from  gangrene  of  tlie  injured  bowel. 

The  transverse  is  more  often  affected  than  the  descending  portion 
of  the  duodenum,  and  the  rupture  usually  occurs  more  or  less  trans- 
venscly  to  the  long  axis  of  the  intestinal  canal.     The  bowel  may  be 


Injuries  of  the  Duodenum.  339 

completely  torn  across.  This  is  not  unusual  at  or  near  the  duodeno- 
jejunal juncture,  as  in  Moynihan's  case;  the  explanation  probably 
being  that  the  greatest  strain  is  felt  where  the  fixed  portion  ceases  and 
the  movable  portion  of  the  bowel  commences.  The  causes  are  blows 
(especially  kicks  from  horses),  falls  and  crushes.  Perry  and  Shaw 
refer  to  a  case  of  rupture  of  the  duodenum  produced  by  vomiting; 
ruptures  of  the  stomach  existed  in  the  same  patient;  none  of  the 
lesions  were  discovered  during  life. 

Suture  should  be  done  where  this  is  possible.  If  doubt  exist  as  to 
the  viability  of  the  injured  gut,  excision  had  best  be  done,  difficult  as 
such  an  operation  is.  Sometimes  end-to-end  anastomosis  is  possible. 
In  Moynihan's  patient,  referred  to  above,  a  boy  of  6  years,  a  few 
inches  of  damaged  gut  were  resected,  the  proximal  end  of  the  duo- 
denum was  closed,  and  the  distal  end  (origin  of  the  jejunum)  was 
united  to  the  stomach;  as  a  result  the  whole  of  the  bile  and  pan- 
creatic juice  passed  into  the  stomach  in  order  to  reach  the  jejunum. 
As  already  mentioned,  this  patient  survived  in  excellent  health  for 
104  days,  and  died  then  from  perforation  of  the  bowel  by  the  Murphy 
button  which  had  been  used  in  making  the  anastomosis.  Meerwein 
found  in  his  patient  a  complete  transverse  rupture  of  the  duodenum 
where  it  crossed  the  spinal  column.  It  was  impossible  to  close  the 
rupture  by  an  end-to-end  anastomosis.  Accordingly  the  proximal 
end  was  closed  by  a  purse-string  suture  ;  the  distal  end  was  then  drawn 
out  from  beneath  the  root  of  the  mesentery  to  the  patient's  left,  the 
devitalized  portion  of  the  gut  was  excised,  and  the  remaining  (distal) 
end  of  the  duodenum  closed.  A  lateral  anastomosis  was  then  made 
between  the  posterior  wall  of  the  stomach  and  the  upper  jejunum 
(trans-mesocolic  posterior  gastro-jejunostomy);  and  finally  a  lateral 
anastomosis  was  made  between  the  juxta-pyloric  portion  of  the  duo- 
denum and  the  jejunum  about  60  cm.  (24  inches)  from  the  origin  of 
the  latter  (anterior  ante-colic  duodeno-jejunostomy).  As  a  precaution 
gauze  drains  were  left  to  all  the  sutured  areas.    The  patient  recovered. 

REFERENCES. 

Cackovic:  Arch.  f.  klin.  Chir.,  1903,  Ixix,  S54. 
Gage:  Annals  of  Surgery,  1902,  i,  331. 


340     Injuries  of  Diaphragm,  Stomach,  and  Duodenum. 

Harte:   Annals  of  Surgery,  1902,  i,  116. 

Meenvein:   Beitr.  z.  klin.  Chir.,  1907,  liii,  496. 

Moynihan:   Brit.  Med.  Jour.,  May,  1901. 

Perry  and  Shaw:   Guy's  Hospital  Reports,  1893,  1,  171. 

Sherwood:   Brooklyn  Med.  Jour.,  1906,  xx,  62. 

Summers:  Annals  of  Surgery,  1904,  xxxix,  727. 


CHAPTER   XIV. 

TECHNIQUE  OF  OPERATIONS. 

Preparation  for  Operation. — Whenever  practicable,  it  is  well 
for  the  patient  to  pass  a  night  or  two  in  the  hospital  before  the 
day  set  for  operation.  In  cases  of  perforation  or  of  hemorrhage,  if 
the  surgeon  think  it  proper  to  operate  for  the  latter  as  an  acute  con- 
dition, there  is  of  course  no  time  for  delay.  When  feasible,  from  24 
to  48  hours  should  be  devoted  to  putting  the  gastro-intestinal  tract  in 
as  good  a  condition  for  operation  as  possible.  For  at  least  twenty- 
four  hours  before  operation  only  cooked,  and  therefore  sterile,  food 
should  be  given  the  patient.  The  mouth  and  teeth  should  be  thor- 
oughly cleansed  after  each  meal  and  at  bed-time  with  an  astringent 
and  mildly  antiseptic  wash.  Dilute  alcohol,  boric  acid,  peroxide  of 
hydrogen,  etc.,  are  among  the  drugs  employed  in  such  a  w^ash. 
The  mouth  should  be  kept  as  free  as  possible  from  any  particles  of 
food  which  may  undergo  fermentation. 

A  brisk  purge  should  be  administered  the  day  before  operation, 
preferably  in  the  morning.  Usually  either  Epsom  salts  or  castor  oil 
should  be  chosen,  but  the  preference  of  the  patient  may  be  consulted. 
If  given  in  the  morning  of  the  day  before  operation,  the  effect  of  the 
purge  will  wear  off  during  the  day,  thus  allowing  the  patient  to  have 
an  undisturbed  night  preceding  the  operation.  On  the  morning  of  the 
day  of  operation,  an  enema  should  be  given  to  empty  the  lower  bowel. 

After  the  purge  has  acted,  very  little  if  any  food  should  be  given  the 
patient.  If  any  be  given,  it  should  consist  entirely  of  such  material 
as  will  be  readily  absorbed  and  will  leave  little  if  any  residue  in  the 
intestinal  tract. 

The  patient  may  drink  freely  of  sterile  water  until  within  a  few 
hours  of  the  operation.  The  stomach  should  be  empty  at  the  time 
of  operation,  but  it  is  only  in  exceptional  cases  that  it  must  be  emptied 
by  means  of  the  stomach  tube.     Where  there  is  marked  stasis,  es- 

341 


342  Technique  of  Operations. 

pecially  if  there  are  putrefactive  changes  in  the  stomach,  it  is  always 
advisable  to  empty  the  organ  immediately  before  operation. 

Preparation  of  the  Abdomen. — The  routine  method  employed 
at  the  German  Hospital  in  preparing  the  field  of  operation  is  as 
follows :  On  the  morning  of  the  operation,  the  abdomen  is  thoroughly 
w^ashed  with  green  soap  and  water,  special  attention  being  paid  to  the 
navel.  The  entire  abdomen  is  shaved  and  again  washed  wdth  the 
green  soap  and  water,  gauze  being  used  instead  of  a  brush.  It  is 
then  rinsed  with  sterile  water,  rubbed  with  60  per  cent,  alcohol,  and 
then  with  a  1-2000  solution  of  corrosive  subKmate,  and  finally  rinsed 
sparingly  with  Harrington's  solution,  the  formula  of  which  is 

Hydrargyri  Chloridi  Corros 3.2 

Ac.  Hydrochlor.  Dil 240.0 

Aq.  Destil 1200.0 

Alcohol  (grain) 2650.0 

This  solution  is  very  irritating  and  should  be  removed  from  the  skin 
in  about  thirty  seconds  by  rinsing  the  part  with  alcohol.  A  large 
sterile  gauze  dressing  is  then  applied  to  the  abdomen.  This  is  removed 
after  the  patient  has  been  placed  on  the  operating  table,  after  ano?s- 
thetization.  The  field  of  operation  is  then  again  thoroughly  washed 
with  green  .soap  and  water,  with  60  per  cent,  alcohol,  and  with  a  1- 
2000  bichloride  solution. 

General  Considerations  on  Operative  Technique. — Anaes- 
thetic. Pother  is  used  almost  without  exception.  Sometimes  amTs- 
thcsia  is  induccfl  with  nitrous  oxide  gas,  etlicr  being  substituted  as 
soon  as  consciousness  is  lost;  but  as  a  rule  ether  is  employed  from  tlic 
beginning,  the  so-called  "open,  drop-method"  invariably  being 
used.  Ethyl  chloride  is  never  used;  it  is  seductive  but  dangerous. 
The  patient  is  placed  upon  the  operating  table  in  the  etherizing  room, 
before  anesthesia  is  begun.  We  believe  that  this  method  reduces  the 
amount  of  ether  administered,  ensures  the  i)atient  lying  on  the  table  in 
as  nearl_\-  normal  an  altilude  as  ])()ssil)lc,  and  thus  is  afh'antageous  in 
every  resi)ect.  Ether  is  discontinued  as  soon  as  possible,  and  as  the 
abdominal  wound  is  l)eing  sutured  oxygen  is  administered,  so  that 
consciousness  begins  to  return  as  the  dressing  is  api)]ied.  To  main- 
tain bodily  warmth  during  the  operation,  the  table  is  covered  with  a 


Instruments.  343 

hot  water  bed,  and  the  patient  wears  a  cotton  jacket  and  has  the  legs 
and  arms  bandaged  in  the  same  material,  or  wears  long  stockings  of 
canton  flannel.  When  the  patient  is  transferred  to  bed,  if  he  is 
perspiring  freely,  it  is  best  to  change  the  cotton  jacket  for  a  light 
woolen  undershirt. 

Assistants.  At  the  German  Hospital,  one  assistant,  the  senior 
Resident  Surgeon  then  on  duty,  helps  the  surgeon  during  the  opera- 
tion. One  Sister  threads  needles,  hands  instruments,  etc.;  another 
is  in  charge  of  the  gauze  sponges  and  hands  them  to  the  surgeon  as 
required ;  while  a  third  changes  the  saline  solutions,  keeping  them 
constantly  clean  and  hot;  and  a  fourth  also  keeps  account  of  all  pieces 
of  gauze  used,  reporting  from  time  to  time  to  the  Sister  in  charge  of 
the  gauze,  who  is  responsible  for  the  final  reckoning  of  pieces  of  gauze 
employed  during  the  operation.  The  surgeon  does  all  the  operating 
himself;  the  assistant  holds  retractors,  and  so  disposes  the  operative 
field  as  to  make  operating  easy. 

Instruments.  Very  few  special  instruments  are  required. 
Good  retractors  are  a  necessity.  Rubber-covered  clamps  are  ex- 
tremely desirable.  For  many  years  no  clamps  were  used  at  the 
German  Hospital  except  for  gastrectomy;  but  even  in  performing 
gastro-enterostomy  it  cannot  be  denied  that  their  use  considerably 
simplifies  matters,  by  rendering  more  rapid  operating  possible,  as  well 
as  by  lessening  the  chances  of  infection.  Mechanical  aids  for  gastro- 
intestinal anastomosis,  such  as  the  Murphy  button,  are  never  used 
except  in  emergencies,  where  it  is  desirable  to  terminate  the  operation 
rapidly,  or  in  positions  where  the  application  of  sutures  is  particularly 
difficult.  Thus  .in  doing  anterior  gastro-jejunostomy,  which  is  re- 
served for  patients  with  gastric  cancer  so  far  advanced  as  to  make 
even  a  posterior  palliative  operation  impossible,  the  Murphy  button 
sometimes  is  used,  so  as  to  keep  the  abdomen  open  the  very  shortest 
possible  time.  Sometimes  also,  after  extensive  gastrectomies,  where 
the  cardiac  stump  is  very  small,  it  is  better  to  use  a  IMurphy  button 
than  to  attempt  formally  to  suture  structures  which  are  nearly  in- 
accessible. Gauze  packs  are  absolutely  requisite  to  protect  the 
general  peritoneal  cavity,  to  keep  other  abdominal  viscera  from  pro- 
lapsing into  the  wound,  and  to  maintain  the  vital  heat  of  those  struc- 


344 


Technique  of  Operations. 


tures  which  are  exposed.  These  packs  are  about  ten  inches  square, 
and  are  made  by  basting  together  six  to  eight  layers  of  gauze.  They 
are  wrung  out  of  hot  sahne  solution  as  required,  and  are  handed  to 

the  surgeon  hot. 

Sutures. — Two  main  types 
of  sutures  are  used — the  Czerny 
(through-and-through)  and  the 
Lembert  (sero-serous),  as  shown 
diagrammatically  in  Fig.  34.  The 
combined  Czerny-Lembert  suture 
is  sometimes  spoken  of  as  Wolfler's 
suture.  The  Czerny  suture  is 
invariably  of  absorbable  material ; 
at  the  German  Hospital  iodized 
catgut  is  employed.  Many  sur- 
geons still  prefer  chromicized  cat- 
gut. This  suture  is  designed  to 
be  haemostatic,  and  should  stay 
in  the  tissues  long  enough  not 
only  to  make  the  anastomosis  secure  against  secondary  hemor- 
rhage, but  to  procure  firm  union  between  the  margins  of  the  stom- 
ach  or   intestine   involved.     It  should    not,    however,    be   of   non- 


FlG.  34. 


Fig.  35- 


Fig.  36. 


absorbable  material,  since  then  it  may  ulcerate  out  at  one  ];lace,  and 
by  hanging  as  a  kx)p  in  the  lumen  of  the  newly  formed  channel 
(Fig.  18)  j)Ossibly  be  the  cause  of  obstruction.  Or  the  portions  of 
the  suture  still  embedded  in  the  tissues  may  be  torn  out  by  the  drag 


Sutures  and  Suture  Material. 


345 


of  the  loop  which  has  ulcerated  out,  and  secondary  hemorrhage  may 
be  started.  These  through-and-through  sutures  are  always  used  as 
a  continuous  suture;  if  there  should  be  danger  of  the  suture  pucker- 
ing the  anastomosis,  this  may  easily  be  prevented  by  arresting  the 
suture  by  a  knot  at  three  or  four  points  as   it  passes  around  the 


Fig.  37. 


Fig.  38. 


circumference   of  the  anastomosis.      Special  stress  is    laid  on  this 
matter  by  Hartmann. 

Sero-Serous  Sutures.  Various  forms  of  this  general  type  are 
shown  in  the  accompanying  illustrations.  Linen  thread  is  used  in  all 
cases,  and  the  needle  picks  up  all  the  coats  but  the  mucous,  i.  In- 
terrupted Lembert  Suture  (Fig.  35)  is  especially  applicable  for  re- 
inforcing a  continuous  Lembert  suture  at  any  point  where  it  appears 


Fig.  39. 


Fig.  40. 


likely  to  leak.  2.  Continuous  Lembert  Suture  (Fig.  38)  is  that  which 
is  most  often  used  in  all  forms  of  intestinal  surgery.  The  suture  is 
commenced  by  catching  up  on  the  needle  a  bite  of  the  serous,  muscular, 
and  submucous  coat  on  each  side  of  and  a  little  beyond  the  end  of  the 
intestinal  wound,  the  needle  being  held  at  right  angles  to  the  wound. 


346 


Technique  of  Operations. 


The  suture  is  fixed  at  its  starting  point  by  tying  a  surgeon's  knot 
(Fig.  36).     The  needle  then  again  picks  up  all  the  coats  but  the 


Fig.  41. 


Fig.  42. 


mucous  on  each  side  of  the  wound,  crossing  back  to  the  original  side 
of  the  wound  before  commencing  each  new  stitch  (Fig.  37),  and  thus 

continues  until  the  other  end  of 
the  wound  is  reached,  where  the 
thread  is  knotted  as  shown  in  Fig. 
38.  Should  the  suture  be  too 
short  to  reach  the  entire  length  of 
the  wound,  or  should  it  unfortun- 
ately break,  it  may  be  knotted  at 
any  point,  and  a  new  suture 
started  (Fig.  39).  3.  Interrupted 
Mattress  Suture  (Fig.  40):  this  is 
particularly  adapted  for  places 
where  the  intestine  is  friable,  or 
Avhcrc  llierc  is  much  tension  on  the 
sutures.  4.  Continuous  Mattress 
Suture  is  shown  in  Fig.  41.  5. 
Right  Angled*  Suture  (Fig.  42), 
in  which  the  needle  is  inserted 
])arallel  to  the  edges  of  the  intes- 
tinal wound,  secures  excellent 
a])])ro.\imati{)n,  and  is  often  ])ref- 
crable  to  the  continuous  mattress 
suture,  because  it  can  be  ai)])lied  so]much  more  quickly. 

Closure  of   the  Abdominal  Wound. — The  peritoneum  is  su- 


FiG.  43. 


Closure  of  the  Abdominal  Wound. 


347 


tured  by  a  continuous  catgut  suture,  in  such  a  way  that  the  serous 
surfaces  are  everted  into  the  wound,  thus  bringing  serosa  against 
serosa,  ensuring  rapid  union,  and  leaving  no  projections  within 
the  abdomen  to  favour  adhesions  between  the  scar  and  omentum  or 
other  abdominal  viscera  (Fig.  43).  This  suture  should  begin  and  end 
beyond  the  extremities  of  the  peritoneal  wound,  since  this  is  apt  to  split 
further  unless  thus  reinforced.     The  end  of  the  peritoneal  suture,  still 


Fig.  44. 


threaded,  is  left  long;  while  two  or  three  "splint  sutures"  of  silkworm 
gut  are  introduced  from  the  skin  surface  of  one  side  through  all  struc- 
tures but  the  peritoneum,  and  out  again  through  the  other  side  of  the 
wound  (Fig.  44).  If  the  abdominal  incision  is  very  short,  it  is  not 
necessary  to  use  these  splint  sutures ;  but  in  any  wound  of  more  than 
three  inches  it  is  safer  to  employ  them.  They  act  not  only  as  tension 
sutures,  relieving  the  strain  on  the  buried  (absorbable)  sutures,  but 


348 


Technique  of  Operations. 


they  also  obhtcrate  all  dead  spaces  between  the  different  layers  of  the 
abdominal  wall,  thus  preventing  the  formation  of  haematomata  and 
subsequent  infection.  When  these  splint  sutures  have  all  been 
placed,  but  before  they  are  tied,  the  peritoneal  suture  first  employed  is 
continued  downward,  as  shown  in  Fig.  45,  uniting  the  anterior  sheath 
of  the  rectus,  and  is  finally  tied  to  its  own  initial  extremity  (A  to  B). 
Finally  the  splint  sutures  are  tied.     (Fig.  46.)     In  suturing  an  in- 


FlG.  45. 


cision  in  a  very  obese  patient,  it  is  not  desiraljle  to  close  the  skin 
surface  too  tightly.  It  is  safer  to  leave  space  between  the  sutures  for 
drainage  of  the  products  of  fat  necrosis.  In  most  patients,  however, 
accurate  apjxjsilion  of  the  sidn  surfaces  of  the  wound  is  obtained 
by  a  running  suture,  and  the  sph'nt  sutures  are  tied  ovxt  a  roll  of 
gauze. 

After-Treatment,      I'hc    motlo    for   Residents   at   the   German 


After-Treatment. 


349 


Hospital  is  "Let  tlie  patient  get  well."  Very  little  after-treatment 
except  careful  nursing  is  required.  The  patients  are  raised  up  in  bed 
as  soon  as  the  effects  of  the  ether  pass  away.  The  head  of  the  bed  is 
also  raised  about  15  degrees  from  the  horizontal.  They  are  kept 
in  a  sitting  posture  by  a  pillow  under  their  buttocks,  and  this  pillow 
is  kept  in  place  by  a  sheet  which  is  slung  under  it  and  fastened  to 
the  head  of  the  bed.  Vomiting  is  unusual;  it  is  treated  by  total 
abstinence  from  mouth  feeding;    by  sitting  the  patient  up  in  bed; 


Fig.  46. 


by  the  administration  of  a  glass  of  hot  w^ater;  and  finally  by  lavage. 
The  patients  do  not  have  much  pain.  If  they  do  suffer  from  pain, 
the  Resident,  after  consultation  with  the  surgeon,  is  authorized  to 
administer  a  hypodermatic  injection  of  one-twelfth  of  a  grain  of  mor- 
phine. But  a  minimum  quantity  of  ether,  speedy  and  orderly  oper- 
ating, and  the  routine  administration  of  oxygen,  render  the  subsequent 
use  of  morphine  exceptional ;  it  is  given  in  this  way  in  perhaps  five 
per  cent,  of  abdominal  operations.     Under  no  circumstances  at  the 


350  Technique  of  Operations. 

German  Hospital  is  the  Resident  permitted  to  give  a  dose  of  morphine 
without  consuhing  the  surgeon.  Feeding — liquid  diet — is  not  begun 
for  from  48  to  72  hours  after  operation;  at  first  small  pieces  of  ice  are 
allowed;  then  buttermilk,  broths,  etc.;  and  unless  nausea  prevents, 
soft  diet  is  allowed  in  three  or  four  days.  At  the  end  of  ten  days  or 
two  weeks  the  patients  are  encouraged  to  get  up ;  but  they  should  not 
be  hurried  out  of  the  hospital  before  their  wounds  are  entirely  healed, 
nor  until  they  are  able  to  take  care  of  themselves. 


Gastrotomv.  351 


GASTROTOMY. 

Indications,  i.  For  the  removal  of  foreign  bodies  from  the 
stomach,  or  from  the  lower  end  of  the  oesophagus. 

2.  As  a  prehminary  to  the  dilatation  of  stricture  of  the  pylorus, 
the  cardia  or  the  oesophagus. 

3.  For  the  control  of  hemorrhage  within  the  stomach. 

4.  For  the  removal  of  polypi  or  other  pedunculated  tumors  from 
the  interior  of  the  stomach. 

5.  As  an  incident  in  certain  operations  on  the  posterior  wall  of  the 
stomach. 

Incision.  This  is  to  be  made  through  the  left  rectus  muscle  close 
to  the  median  hne,  from  the  tip  of  the  ensiform  process  downward  for 
about  three  inches  (7.5  cm.). 

Exploration.  Locate  the  left  lobe  of  the  liver;  immediately  be- 
neath this  is  the  stomach.  While  the  assistant  raises  the  margins  of 
the  abdominal  incision  with  retractors,  inspect  the  anterior  gastric  wall. 
If  the  colon  bulges  into  the  wound,  pack  in  large  gauze  pads  until  it 
stays  out  of  the  operative  field.  If  the  operation  is  for  the  removal  of 
a  foreign  body,  palpate  the  stomach  gently,  and  try  to  locate  the  body 
to  be  extracted.  When  the  foreign  body  has  been  fixed  with  the 
fingers  in  contact  with  the  anterior  gastric  wall,  other  gauze  pads 
should  be  introduced  so  as  to  isolate  completely  the  portion  of  the 
stomach  wall  to  be  opened.  The  stomach  may  be  grasped  with 
rat-tooth  or  Allis  forceps,  to  facilitate  this  part  of  the  operation. 

Opening  the  Stomach.  When  the  stomach  has  been  isolated 
thus  a  small  incision  may  be  made  in  its  anterior  wall  with  a  scalpel. 
If  the  object  is  to  remove  a  foreign  body,  no  longer  an  incision  should 
be  made  than  is  absolutely  necessary  to  extract  the  foreign  body; 
and  under  these  circumstances  the  incision  is  best  made  transverse  to 
the  long  axis  of  the  stomach,  parallel  with  the  gastric  blood  vessels. 
If,  however,  the  stomach  must  be  more  widely  opened,  as  for  ex- 


352  Technique  of  Operations. 

ploration  of  the  oesophagus  or  the  removal  of  an  endogastric  polyp, 
the  incision  in  its  wall  is  best  made  longitudinally,  and  any  bleeding 
points  should  be  caught  in  hcemostatic  forceps,  which  will  then  serve 
the  useful  purpose  of  retractors.  For  exploring  the  oesophagus  the 
incision  should  be  made  beneath  the  cardiac  orifice,  while  if  the  py- 
lorus is  to  be  dilated,  or  a  pyloric  polyp  removed,  the  surgeon  will 
naturally  place  his  incision  nearer  to  it.  In  exploring  the  oesophagus 
it  is  well  to  bear  in  mind  that  the  lower  end  of  the  oesophagus  turns 
toward  the  patient's  left,  and  that  the  cardiac  orifice  is  frequently 
more  or  less  obscured  by  a  fold  of  mucous  membrane.  Nine  times 
out  of  ten  the  inexperienced  operator  will  vainly  endeavour  to  poke  a 
hole  through  the  fundus  of  the  stomach,  pointing  his  finger  to  the 
patient's  head,  instead  of  obliquely  to  his  right. 

Closing  the  Stomach.  When  the  endogastric  manipulations 
have  been  concluded,  the  stomach  wall  is  to  be  sutured  with  at  least 
two  layers  of  sutures  (Czerny-Lembert).  The  stomach  is  then  al- 
lowed to  fall  back  into  the  abdomen;  the  gauze  packs  are  removed; 
and  the  abdominal  wound  closed  in  the  usual  way  without  drainage. 


Gastrostomy.  353 


GASTROSTOMY. 

Indications,  i.  Impermeable  stricture  of  the  oesophagus,  or 
malignant  obstruction  of  the  cardiac  orifice  of  the  stomach. 

2.  It  has  been  urged  by  certain  European  surgeons  as  a  method  of 
treatment  of  diffuse  peritonitis. 

3.  A  modified  form  of  gastrostomy  may  be  necessary  in  cases  of 
phlegmonous  gastritis. 

The  operation  of  gastrostomy,  according  to  Sencert,  was  first 
suggested  as  a  remedy  for  stricture  of  the  oesophagus  by  Engelbert,  a 
Norwegian,  in  1837.  It  was  first  performed  in  1849,  ^7  Sedillot,  of 
Strasbourg.  In  most  cases  in  which  it  is  adopted  it  is  desirable  to 
establish  a  more  or  less  permanent  opening  for  the  purpose  of  intro- 
ducing food  into  the  stomach.  But  in  addition  to  the  permanency  of 
the  fistula,  it  is  extremely  desirable  to  have  a  continent  opening,  one 
which  will  not  leak ;  for  leakage  will  not  only  deprive  the  patient  of  the 
benefit  of  the  food  which  has  been  introduced,  but  will  keep  his  cloth- 
ing constantly  wet  between  feedings,  by  allowing  the  escape  of  the 
gastric  juice.  A  third  desideratum,  much  less  important,  however, 
than  those  just  mentioned,  is  that  the  fistula  shall  close  spontaneously 
when  it  is  no  longer  needed. 

Among  the  many  methods  which  have  been  devised  for  the  per- 
formance of  gastrostomy,  it  is  our  intention  to  describe  only  the 
following:  i.  The  methods  of  Witzel,  of  Senn,  and  of  Kader,  all  of 
which  are  based  on  the  principle  of  inverting  the  gastric  wall  so  as  to 
form  a  funnel-like  channel  from  the  cavity  of  the  stomach  to  the  wall 
of  the  abdomen.  2.  The  Ssbanajew-Frank  method,  in  which  a  cone 
of  the  anterior  gastric  wall  is  brought  out  and  laterally  displaced  be- 
neath a  bridge  of  skin  before  being  opened.  3.  The  method  of 
Tavel,  of  Roux,  and  of  Herzen,  in  which  a  segment  of  the  jejunum  is 
used  as  the  fistulous  tract  between  the  stomach  and  the  skin. 


354 


Technique  of  Operations. 


I.  Methods  of  Witzel,  Senn,  and  Kader. — Incision.  The 
incision  is  made  in  the  left  rectus  muscle  near  its  outer  margin,  from  a 
little  belowthe  costal  margin  downward  for  about  three  inches  (7.5  cm.). 
If  the  interior  of  the  stomach  is  to  be  explored,  as  in  cases  of  stricture 
of  the  oesophagus,  or  for  other  reason,  the  operation  of  gastrotomy,  as 
described  on  page  351,  will  first  be  performed;  and  then  the  incision 
in  the  anterior  gastric  wall  should  be  closed  except  at  one  end,  where 
an  opening  should  be  left  just  large  enough  to  admit  a  large  rubber 
catheter  (Nos.  26  to  28  French)  or  drainage  tube.  The  gastrostomy 
opening  should  be  made  about  midway  between  the  greater  and 
lesser  curvatures,  and  in  the  cardiac  portion  of  the  stomach,  not  within 

the  pyloric  antrum.  If  made 
in  the  antrum,  the  active 
peristaltic  contractions  may 
not  only  interfere  with  adhe- 
sions of  the  stomach  to  the 
anterior  abdominal  wall,  but 
there  also  will  be  greater 
tendency  toward  leakage  of 
the  gastric  contents  than  is 
the  case  when  the  opening 
is  made  in  the  region  of  the 
fundus. 

(a)  Witzel's  Method. 
The  catheter  is  laid  on  the 
anterior  wall  of  the  stomach 
with  its  gastric  end  toward  the  pyloric  end  of  the  stomach;*  and 
the  stomach  wall  is  then  sutured  over  it  by  a  row  of  sero-serous 
sutures  (interrupted).  When  the  catheter  is  thus  fixed  in  a  serous 
channel,  a  small  opening  is  made  in  the  gastric  wall  at  the  pyloric 
extremity  of  the  infolded  area,  the  gastric  end  of  the  catheter  is 
passed  through  this  into  the  stomach  for  about  an  inch  or  an  inch 
and  a  half,  and  is  anchored  in  place  by  a  single  catgut  suture  passing 
through  the  catheter  and  through  the  entire  thickness  of  the  gastric 

*  Gould  advises  that  the  catheter  be  placed  parallel  with  the  lesser  curvature,  its 
eye  pointing  upward. 


Fig.  47. — ^Witzel's  Gastrostomy.    Suturing 
THE  Catheter  in  Place. 


Gastrostomy. 


355 


wall.  The  opening  in  the  stomach  wall  is  then  buried  by  a  few  ad- 
ditional sutures.  All  these  sutures  should  be  of  linen^  except  that 
used  to  fix  the  catheter  in  the  gastric  opening;  by  using  plain  catgut 
for  this,  the  suture  will  be  absorbed  in  four  or  five  days,  when  the 
catheter  may  be  removed,  washed,  and  replaced;  since  by  this  time 
the  adhesions  of  the  stomach  to  the  anterior  abdominal  wall  will  make 
the  temporary  removal  of  the  catheter  quite  safe.  The  catheter 
should  be  clamped  at  its  outer  end  to  prevent  leakage  of  gastric  con- 
tents through  it  during  the  remaining  steps  of  the  operation.  The 
stomach  should  now  be  sutured  to  the  margin  of  the  abdominal  in- 
cision by  three  or  four  interrupted  sutures  which  pass  through  all  the 
structures  of  the  abdominal  wall 
except  the  skin  and  the  superficial 
fascia.  These  sutures  should  be 
of  linen.  One  should  be  inserted 
on  each  side  of  the  point  where 
the  catheter  emerges  from  the 
stomach,  another  being  placed 
above  or  below,  or  in  both  situa- 
tions, as  may  seem  requisite. 
The  abdominal  wound  is  to  be 
closed  in  the  usual  way  without 
drainage,  except  for  such  drain- 
age as  takes  place  along  the  tract 
of  the  catheter. 

(6)  E.  J.  Senn's  Method.* 
A  small  incision,  just  large  enough 
to  admit  the  catheter,  is  made  in 

the  anterior  gastric  wall;  the  catheter  (its  outer  end  clamped)  is 
inserted  for  about  an  inch  inside  the  cavity  of  the  stomach,  and 
is  fixed  in  the  gastric  wall  by  a  single  suture  of  catgut.  Then 
a  purse-string  suture  of  linen  is  taken  in  the  stomach  wall,  circu- 
larly around  the  catheter,  and  about  three-fourths  of  an  inch  (2 
cm.)  distant  from  it;   as   this   suture   is   tightened  the   catheter  is 

*  Practically  the  same   operation  had  been  described  two  years  previously  by 
Stamm  (1894). 


Fig.  48. — Witzel's  Gastrostomy.    Clo- 
sure OF  THE  Abdominal  Wound. 


356  Technique  of  Operations. 

pushed  toward  the  cavity  of  the  stomach,  carrying  with  it  the  incision 
in  the  stomach  wall,  and  thus  inverting  the  gastric  wall  so  that  the 
catheter  lies  in  a  serous  channel.  Two  other  purse-string  sutures  are 
similarly  passed,  and  as  each  is  tightened  the  inverted  cone  of  gastric 
wall  is  lengthened,  so  that  finally  the  catheter  lies  in  a  channel  of  over 
two  inches  in  length.  The  stomach  is  then  sutured  to  the  abdominal 
wall,  as  in  Witzel's  operation,  and  the  operation  concluded  in  the 
same  way. 

(c)  Kader's  Method.  The  catheter  is  fixed  in  the  gastric  wall  as 
in  the  previous  operation,  and  the  wall  of  the  stomach  is  then  inverted 
by  a  series  of  Lembert  sutures  of  linen  passed  on  opposite  sides  of  the 
catheter;  two  sutures  are  passed  above  the  catheter,  each  picking  up 
the  sero-muscular  coats  of  the  stomach  in  two  places,  so  as  to  form 
two  ridges  with  a  groove  between  them;  two  other  sutures  are  sim- 
ilarly placed  below  the  tube;  then,  as  this  first  series  (consisting  of 
four  sutures)  is  tightened,  the  catheter  is  pushed  inward,  and,  carry- 
ing the  gastric  wall  with  it,  comes  to  lie  in  a  serous  channel  as  in  the 
operations  previously  described.  Two  or  three  layers  of  these  sutures 
are  necessary  to  invert  enough  of  the  gastric  wall,  each  newly  applied 
series  burying  the  preceding  sutures.  The  stomach  is  then  fixed  to 
the  abdominal  wall  in  the  usual  way,  and  the  abdominal  wound  closed. 

Remarks.  Of  these  three  operations,  Senn's  method  is  the 
simplest,  and  requires  less  of  the  gastric  wall  for  its  successful  per- 
formance than  either  of  the  others.  This  is  an  important  point  when 
the  stomach  is  contracted  from  long  disuse  owing  to  oesophageal  or 
cardiac  obstruction.*  We  prefer  it  to  all  other  methods,  in  ordinary 
cases.  The  channel  formed  from  the  ca\-ity  of  the  stomach  to  the 
skin  in  all  these  operations  is  usually  absolutely  continent  so  long  as 
the  catheter  is  in  place;  and  unless  the  catheter  remains  in  the  fistula 
for  some  months  after  the  operation  the  channel  is  ])rone  to  become 
entirely  obliterated  from  adhesion  of  its  serous  surfaces.  Continence 
during  the  ab.scncc  of  the  catheter  from  the  fistula  usually  improves 
some  months  after  the  operation,  and  as  the  serous  lining  will  be 
pretty  well  obliterate<l  by  this  lime,  no  fear  of  spontaneous  closure 
need  be  entertained  if  the  catheter  is  left  out  of  the  fistula  between 
meal  times. 


Gastrostomy.  357 

2.  The  Ssbanajew-Frank  Method. — The  first  operation  by 
Ssbanajew  was  done  in  May,  1890,  and  was  reported  in  Wratsch  for 
that  year;  Frank  independently  devised  the  same  procedure,  and 
employed  it  Nov.  23,  1892,  publishing  his  case  the  following  year. 
Both  operations  are  really  a  modification  of  Hahn's  operation  of 
gastrostomy,  while  Ulmann's  method  of  torsion  of  a  cone  of  the 
gastric  wall  depends  upon  the  same  principle. 

An  incision  about  7  or  8  cm.  (3  inches)  long  through  the  ab- 
dominal wall  is  made  parallel  to  the  left  costal  border,  centered  at  the 
end  of  the  ninth  rib.  A  cone  of  stomach  wall  is  drawn  out  of  this 
incision,  and  at  the  point  on  the  thoracic  wall  reached  by  the  apex 
of  the  gastric  cone  (usually  over  the  sixth  rib,  i  or  2  cm.  (one-half 
to  three-fourths  of  an  inch)  to  the  left  of  the  left  mammillary  line)  a 
second  incision  is  made,  parallel  to  the  first,  but  only  3  or  4  cm.  (one 
and  one-half  inches)  in  length.  This  incision  involves  only  the  skin 
and  fascia.  By  blunt  dissection  a  subcutaneous  channel  is  established 
between  the  two  incisions.  The  parietal  peritoneum  bordering  the 
first  incision  is  then  sutured  to  the  base  of  the  gastric  cone.  The  apex 
of  the  cone  is  then  drawn  through  the  subcutaneous  channel  to  the 
upper  incision,  where  it  is  sutured  to  the  skin.  The  abdominal  in- 
cision is  now  completely  closed.  The  apex  of  the  gastric  cone  may 
now  be  incised,  and  a  drainage  tube  passed  into  the  stomach,  or  its 
opening  may  be  postponed  for  a  couple  of  days  to  permit  firm  adhesions 
to  form. 

Remarks.  This  operation  requires  a  capacious  stomach  for  its 
successful  performance,  and  the  obliquity  of  the  fistula  is  not  main- 
tained very  long,  the  upper  skin  opening  having  a  tendency  to  descend 
below  the  costal  margin  from  the  constant  pull  of  the  stomach  upon 
it.  Where  incontinence  does  not  exist,  the  reason  is  more  likely  to  be 
partial  sphincter-like  action  of  the  abdominal  muscles,  than  the 
obliquity  of  the  gastric  fistula. 

3.  The  Methods  of  Tavel,  of  Roux,  and  of  Herzen. — (a) 
Tavel's  Operation  has  for  its  object  the  formation  of  a  continent 
gastric  fistula,  lined  by  mucous  membrane.  An  incision  is  made 
through  the  left  rectus  muscle,  about  four  inches  (10  cm.)  in  length, 
and  a  well-nourished  loop  of  the  upper  jejunum  is  selected,  provided 


358  Technique  of  Operations. 

with  a  long  mesentery.  The  jejunum  is  then  divided  in  two  places, 
about  live  inches  (12.5  cm.)  apart,  both  sides  of  each  section  being 
guarded  by  rubber-covered  clamps.  The  intervening  portion  of  in- 
testine is  then  excluded  by  doing  an  end-to-end  anastomosis  of  the 
upper  and  lower  segments.  Either  sutures  or  the  Murphy  button  may 
be  used  for  this  purpose.  The  excluded  segment  is  then  transplanted 
through  the  transverse  mesocolon  into  the  lesser  peritoneal  cavity,  and 
through  the  gastro-colic  omentum  out  again  into  the  upper  portion  of 
the  general  peritoneal  cavity.  The  anal  end  of  the  excluded  segment 
(which  must  be  carefully  distinguished  from  the  upper  or  duodenal 
end)  is  then  sutured  into  the  anterior  gastric  wall  (end  to  side  im- 
plantation), and  the  duodenal  end  of  the  gut  is  sutured  into  the  ab- 
dominal wound.  The  remaining  portion  of  the  abdominal  incision 
is  then  closed  in  the  usual  manner.  The  peristaltic  action  of  the 
bowel  thus  tends  toward  the  stomach,  and  a  continent  fistula  is 
established,  lined  with  mucous  membrane,  and  therefore  having  no 
tendency  to  contract. 

Remarks.  Although  we  have  had  no  personal  experience  with 
this  operation,  having  no  reason  to  be  dissatisfied  with  the  results 
obtained  by  Senn's  and  by  Witzel's  methods,  the  few  reported  cases 
in  which  Tavel's  method  has  been  adopted  have  done  well,  and  the 
fistula  has  entirely  fulfilled  the  expectations  of  its  inventor.  It  should, 
however,  be  remarked,  that  the  operation  is  in  itself  a  more  serious 
undertaking  than  those  already  discussed,  and  that  the  time  consumed, 
apart  from  the  shock  of  an  intestinal  resection,  will  be  a  decided  con- 
tra-indication  in  the  case  of  many  patients  in  whom  some  form  of 
gastrostomy  must  be  done.  Lambotte  is  said  to  have  employed 
Tavel's  f)peration  successfully  in  two  patients. 

(b)  Roux's  Operation.  The  purpose  of  this  operation  is  to 
create  a  new  oesophagus  by  transplanting  a  segment  of  the  jejunum 
into  the  subcutaneous  tissue  over  the  sternum,  and  finally  joining  its 
upper  end  to  the  oesophagus  above  the  stricture,  and  its  lower  end  to 
the  stomach.  It  is  interesting  to  trace  the  developement  of  an  opera- 
tion seemingly  so  complicated,  in  1894  l^jirclicr  attcmj)ted  in  two 
patients  to  create  a  channel,  lined  by  skin,  over  the  sternum,  by  means 
of  a  plastic  operation  on  the  skin,  with  the  idea  that  this  channel  should 


Gastrostomy.  359 

serve  as  an  artificial  oesophagus,  by  being  joined  above  to  the  gullet, 
and  below  to  the  stomach.  In  1904  Wullstein  proposed  an  operation 
described  as  "ante- thoracic  oesophago-jejunostomy."  He  worked  out 
the  operation  on  the  cadaver  thus:  he  divided  the  jejunum,  did  an 
anastomosis  in  Y,  drew  the  distal  loop  of  intestine  through  the  trans- 
verse mesocolon  and  the  gastro-colic  omentum,  and  sutured  it  to  the 
skin  of  the  epigastrium.  The  cervical  oesophagus  was  to  be  con- 
nected with  this  jejunal  fistula  by  a  rubber  tube.  Six  months  later 
Gluck  operated  upon  a  patient,  joining  an  oesophageal  cervical 
fistula  to  a  gastric  fistula.  Baudouin,  ignorant  of  others'  work, 
proposed  a  similar  operation  in  1907. 

Roux  (1907)  operated  in  the  following  manner  (see  Deaver  and 
Ashhurst:  Medical  Annual,  Bristol  and  London,  1908,  p.  540): 

Selecting  a  portion  of  jejunum  provided  with  a  long  mesentery, 
he  divided  the  bowel  in  two  places  far  enough  apart  to  allow  of  the 
intervening  portion  reaching  from  the  stomach  to  the  patient's  neck. 
He  then  re-established  the  intestinal  canal  by  means  of  a  Murphy 
button,  and  withdrew  the  excluded  loop  from  the  abdomen  after  de- 
taching only  the  upper  two-thirds  or  so  of  its  mesentery.  Owing  to 
the  anatomical  distribution  of  the  blood  vessels  in  the  upper  jejunum 
this  is  quite  easily  accomplished.  After  implanting  the  distal  end  of  the 
excluded  jejunal  loop  into  the  anterior  wall  of  the  stomach,  the  patient 
was  fed  through  the  transplanted  jejunum,  before  the  subsequent 
steps  of  the  operation  were  undertaken.  A  subcutaneous  channel 
was  next  made  from  the  upper  angle  of  the  abdominal  wound  at  the 
ensiform  process  to  the  upper  sternal  region,  and  the  loop  of  jejunum 
was  carefully  drawn  up  through  this  channel,  and  its  upper  end  sutured 
to  the  skin.  The  arterioles  in  the  gut  thus  transplanted  continued  to 
beat  normally.  A  stomach  tube  was  passed  down  through  the  bowel 
from  the  neck  into  the  stomach,  and  allowed  to  remain  in  place  several 
days,  to  facilitate  feeding  while  the  bowel  acquired  firm  attachments 
in  its  new  situation.  The  progress  of  the  case  was  uneventful.  The 
child  was  ready  to  be  up  when  the  case  was  reported.  Only  a  little 
mucus  was  exuded  from  the  fistula  in  the  neck,  and  no  gastric 
regurgitation  was  ever  observed.  The  operation  as  planned  was  to  be 
concluded  at  a  second  sitting,  in  which  the  oesophagus  above  the 
stricture  was  to  be  united  to  the  jejuno-gastric  fistula. 


360  Technique  of  Operations. 

(c)  Herzen,  of  Moskow,  has  modified  this  operation  of  Roux  by 
transplanting  the  excluded  jejunal  loop  through  the  transverse  meso- 
colon and  the  gastro-colic  omentum,  as  in  Wullstein's  operation;  and 
by  dividing  the  operation  into  three  stages.  The  first  step  is  to  do 
"  Jejunostomia  retro-cohca  ante-thoracica  cervicalis  ypsiliformis," 
much  as  in  Wullstein's  operation.  The  second  stage  consists  in  divid- 
ing the  transplanted  segment  of  jejunum  above  the  Y-anastomosis, 
closing  the  distal  end,  resecting  any  redundant  portion  of  the  proximal 
loop,  and  implanting  the  anal  end  of  the  proximal  loop  into  the 
stomach.  At  the  third  operation,  the  cervical  oesophagus  is  united 
to  the  duodenal  end  of  the  jejunal  loop,  which  was  sutured  to  the 
skin  of  the  cervical  region  at  the  first  operation. 

According  to  Herzen,  the  operation  as  devised  by  Roux  has  been 
carried  out  by  Kocher,  by  Lambotte,  and  by  Gramse,  as  well  as  by 
Herzen  himself.  All  these  patients  had  carcinomatous  obstruction  of 
the  cardia  or  the  oesophagus,  and  all  succumbed,  Herzen's  patient 
living  until  the  fourth  day.  Herzen  did  the  first  stage  of  his  modifi- 
cation of  Roux's  operation  (retro-colic  ante-thoracic  cervical  jejunos- 
tomy  in  Y)  on  a  very  weak  patient  with  cancer,  who  felt  so  much 
better  after  being  fed  through  the  jejunal  fistula  that  he  refused 
further  treatment.  The  entire  operation,  in  three  stages,  was  done  on 
another  patient,  on  Sept.  10,  Oct.  4,  and  Nov.  17,  1907  (the  cervical 
oesophagus  and  the  transplanted  jejunum  being  joined  by  end-to-end 
anastomosis),  with  entire  success,  a  small  oesophageal  fistula  closing 
in  three  weeks,  and  the  patient  being  in  good  health  four  weeks  later, 
when  he  was  shown  to  the  Congress,  and  easily  swallowed  bread,  meat- 
hash,  eggs,  etc.  Intestinal  peristalsis  was  visible  under  the  skin  of 
the  thorax. 

Remarks.  That  the  method  adopted  by  Herzen  is  an  improve- 
ment over  that  of  Roux  is  probably  true;  but  the  same  objection  lies 
against  both  that  we  raised  against  Tavel's  method,  namely,  that  in 
most  jjatients  such  a  severe  operation  will  kill.  If  the  o])cration  is  to 
be  undertaken  for  the  relief  of  carcinomatous  stenoses  this  fact  may 
not  be  thought  to  be  an  objection;  but  the  surgeon  is  not  an  execu- 
tioner. It  does  seem,  however,  that  such  an  ojjcration  as  this  may 
well  be  of  use  in  cases  of  impermeable  benign  stricture  of  the  oesoph- 


Gastrostomy.  361 

agus,  which  have  hitherto  baffled  surgeons  completely.  Internal 
cesophagotomy  and  retrograde  dilatation  in  some  patients  will  con- 
tinue to  fail  in  the  future  as  they  have  in  the  past  to  relieve  the  de- 
plorable condition  of  those  who  must  feed  themselves  through  a  gastric 
fistula;  and  in  such  patients,  whose  general  health  is  good,  but  in 
whom  no  other  means  of  cure  is  available,  the  operations  of  Roux  and 
Herzen  may  be  perfectly  justifiable. 


362 


Technique  of  Operations. 


PYLOROPLASTY. 

Inasmuch  as  the  insufficiency  of  tlie  old-fashioned  pyloroplasty 
has  been  abundantly  demonstrated,  it  is  our  intention  to  describe 
only  Finney's  modification.  Although  Finney  still  prefers  to  use 
the  sutures  as  shown  in  the  accompanying  figures,  most  surgeons 
today  employ  rubber  covered  clamps,  as  in  other  operations  upon 
the  stomach  and  intestines.     The  main  points,  however,  on  which 


Fig.  40. 

stress  is  laid  by  Finney,  arc  first  the  very  thorough  separation  of  the 
pcri-pyloric  adhesions,  and  second  the  large  size  of  the  gastro-duodcnal 
incision,  which  should  be  not  less  than  12  cm.  (over  four  inches  and 
a  half). 

The  operation  is  described  by  Finney  as  follows  (Trans.  Amer. 
Surg.  Assoc,   1902,  XX,  165):   "Divide  the  adhesions  binding  the 


Finney's   Pyloroplasty. 


363 


pylorus  to  the  neighboring  structures,  also  free  as  thoroughly  as 
possible  the  pyloric  end  of  the  stomach  and  first  portion  of  the  duo- 
denum. Upon  the  thoroughness  with  which  the  pylorus,  lower  end  of 
the  stomach  and  upper  end  of  the  duodenum  are  freed,  depends  in 
large  measure  the  success  of  the  operation  and  the  ease  and  rapidity 
of  its  performance.  I  wish  to  emphasize  this  as  one  of  the  most  im- 
portant points  in  the  operation.  Frequently  at  first  sight  the  pylorus 
may  seem  hopelessly  bound  down,  when,  after  a  little  patient  toil  and 
the  judicious  use  of  the  scalpel  and  blunt  dissector,  it  is  found  that  it 


Fig.  50. 


can  be  freed  with  comparative  ease.  A  suture,  to  be  used  as  a  re- 
tractor, is  taken  in  the  upper  wall  of  the  pylorus,  which  is  then  re- 
tracted upward.  A  second  suture  is  then  inserted  into  the  anterior 
wall  of  the  stomach,  and  a  third  into  the  anterior  wall  of  the  duodenum 
at  equidistant  points,  say  about  12  cm.  from  the  suture  just  described 
in  the  pylorus.  These  second  sutures  mark  the  lower  end  of  the 
gastric  and  duodenal  incisions,  respectively.  They  should  be  placed 
as  low  as  possible  in  order  that  the  new  pylorus  may  be  amply  large. 
Traction  is  then  made  upward  on  the  pyloric  suture,  and  downward 


3^4 


Technique  of  Operations. 


in  the  same  plane,  on  the  gastric  and  duodenal  sutures.  This  keeps 
the  stomach  and  the  duodenal  wall  taut,  and  allows  the  placing  of  the 
sutures  with  greater  facility  than  if  the  walls  remained  lax  (Fig.  49) 
The  peritoneal  surfaces  of  the  duodenum  and  stomach  along  its 
greater  curvature  are  then  sutured  together  as  far  posteriorly  as  possible 
(Fig.  50).  For  this  row  I  would  recommend  the  use  of  the  con- 
tinuous suture,  as  it  is  more  easily  and  quickly  applied,  and  it  can  be 
reinforced  after  the  stomach  and  duodenum  ha^e  been  incised.  After 
the  posterior  line  of  sutures  has  been  placed,  an  anterior  row  of 


Fig. 


mattress  sutures  is  taken,  which  are  not  tied,  but  left  long,  in  the 
manner  indicated  in  Fig.  51.  These  sutures,  after  they  have  been 
placed,  are  retracted  vertically  in  either  direction  from  the  middle  of 
the  portion  included  in  the  row  of  sutures  (Fig.  52).  Then,  after  all 
the  stitches  have  Ijecn  placed  and  retracted,  the  incision  is  made  in 
the  shape  of  a  horseshoe.  The  sutures  should  be  placed  far  enough 
apart  to  give  ample  room  for  the  incision.  The  gastric  arm  of  the 
incision  is  made  through  the  stomach  wall  just  inside  the  lowest  point 
of  the  line  of  sutures,  and  is  carried  up  to  and  through  the  pylorus  and 


Finney's   Pyloroplasty. 


36; 


around  into  the  duodenum,  do\Mi  to  the  corresponding  point  on  the 
duodenal  side.  Hemorrhage  is  then  stopped.  It  is  well  to  excise  as 
much  as  possible  of  the  scar  tissue  upon  either  side  of  the  incision  in 
order  to  limit  as  far  as  possible  the  subsequent  contraction  of  the 
cicatrix.  It  is  well,  too,  to  trim  off  with  scissors  redundant  edges  of 
mucous  membrane  at  the  new  pylorus.  A  continuous  catgut  suture 
is  now  taken  through  and  through  all  the  coats  of  the  intestine  on  the 
posterior  side  of  the  incision  (Fig.  53).     This  reinforces  the  posterior 


Fig.  52. 


line  of  sutures,  secures  better  approximation  of  the  cut  edges  of  the 
mucous  membrane,  and  prevents  the  reunion  of  the  divided  intestinal 
walls.  The  anterior  sutures  are  then  straightened  and  tied,  and  the 
operation  is  complete,  unless  one  wishes  to  reinforce  the  mattress 
sutures  with  a  few  Lembert  stitches"  (Fig.  54). 

The  only  modifications  which  we  have  adopted  in  the  limited 
number  of  cases  in  which  this  operation  has  been  done,  consist  in 


366 


Technique  of  Operations. 


(i)  the  use  of  clamps;  (2)  continuing  the  through-and-through  cat- 
gut sutures  all  around  the  gastro-intestinal  anastomosis,  as  in  other 
forms  of  lateral  anastomosis,  instead  of  only  on  the  posterior  surfaces 
of  the  incision,  as  recommended  by  Finney;  and  (3)  in  omitting  the 
anterior  row  of  mattress  sutures,  their  place  being  taken  by  a  con- 
tinuation of  the  posterior  row  of  Lembert  sutures  first  applied.  In 
other  words,  we  do  the  ordinary  operation  of  lateral  anastomosis,  as  in 
gastro-enterostomv  or  entero-enterostomy. 


Fig.  53. 


Durante's  Pyloroplasty.  According  lo  Ricard  and  Chevrier 
Prof.  Durante  has  adojAed  a  form  of  j^yloroplasty  in  which  a  Y  shaped 
incision  is  made  through  the  pyloric  valve  and  the  pyloric  portion  of 
the  stomach.  The  stem  of  the  Y  divides  the  p}'lorus,  and  into  the 
incision  thus  made,  the  triangular  flap  included  between  the  branches 
of  the  Y  is  drawn  and  sutured,  thus  increasing  the  diameter  of  the 
pylorus  at  the  expense  of  the  anterior  gastric  wall.     The  i)rinciple 


Gastro-Duodenostomy. 


367 


is   the  same  as  in  Nicoll's  operation  for  infantile  stenosis  of  the 
pylorus. 

Kocher's  Method  of  Lateral  Gastro-Duodenostomy  is  ren- 
dered possible  by  mobilization  of  the  duodenum,  adopted  years  ago 


Fig.  54. 


by  Finney,  and  recently  popularized  by  Kocher.  Leriche  gives  the 
history  of  this  preliminary  step,  the  idea  of  mobilizing  the  duodenum 
apparently  having  originated  with  Terrier.  The  operation  resembles 
that  of  Finney,  except  that  the  pylorus  itself  is  not  divided.  We  have 
employed  this  operation  in  a  few  cases,  with  satisfactory  results. 


:> 


68  Technique  of  Operations. 


GASTRO-JEJUNOSTOMY. 

Historical.  The  operation  was  first  performed  in  1881  (at  the 
suggestion  of  his  assistant  Nicoladoni),  by  Wolfler.  The  case  was 
one  of  pyloric  carcinoma,  and  when  this  was  found  to  be  inoperable, 
Wolfler  was  about  to  close  the  abdomen,  when  Nicoladoni  suggested 
that  by  anastomosing  the  small  bowel  with  the  anterior  wall  of  the 
stomach  a  new  exit  for  the  food  would  be  provided.  Although  in 
this  original  operation  the  jejunum  was  attached  to  the  stomach  in  an 
anti-peristaltic  direction  (that  is,  with  its  anal  end  toward  the  cardiac 
end  of  the  stomach),  yet  it  is  customary  to  speak  in  general  of  all 
anterior  gastro-jejunostomies  as  done  by  Wolfler's  method.  In  1887 
Rockwitz  introduced  an  operation  in  which,  by  attaching  the  jejunum 
to  the  stomach  in  the  other  direction,  "iso-peristaltic"  action  was  ob- 
tained. In  1885  V.  Hacker  published  a  method  of  gastro-jejunostomy 
by  which  the  anastomosis  was  made  in  the  posterior  wall  of  the 
stomach,  through  an  opening  in  the  transverse  mesocolon.  Since  that 
time  all  posterior  trans-mesocolic  gastro-jejunostomies  by  lateral  an- 
astomosis have  been  described  in  general  as  by  v.  Hacker's  method. 

The  idea  of  a  gastro-jejunostomy  in-Y  is  attributed  by  Roux  to 
Socin;  but  the  latter  credits  its  origin  to  Wolfler,  who  in  his  "second" 
method  adopted  this  technique  in  connection  with  anterior  gastro- 
jejunostomy. Roux  cafls  his  own  method  "posterior  retro-cohc  gastro- 
enterostomy in-Y." 

The  idea  of  doing  an  entero-anaslomosis  Ijctwecn  the  afferent  and 
efferent  loops  of  the  jejunum,  supposed  to  ])revent  the  discharge  of 
the  duodenal  secretions  into  the  stomach,  is  due  to  Lauenstein,  who 
suggested  in  i8gi  the  anastomosis  of  the  afferent  loop  with  a  neigh- 
bouring coil  of  intestine.  I^^raun  in  1892  acl()])ted  as  his  method  an 
anastomosis  between  the  afferent  and  efferent  loops;  while  Jaboulay, 
in  the  same  year,  anastomosed  the  jejunum  below  the  gastro- jejunal 
anastomosis  with   the  third  portion  oi  tlie  duodenum.      To  make 


History  of  Gastro-Jejunostomy. 


369 


certain  that  the  contents  of  the  afferent  loop  would  pass  directly 
into  the  efferent,  through  the  entero-anastomosis,  and  not  continue 
past  it  into  the  stomach,  the  af- 
ferent loop  (between  the  stomach 
and  the  entero-anastomosis)  was 
divided  and  both  ends  closed  by 
Doyen  in  1898;  while  Fowler,  in 
1902,  was  content  to  ligate  the 
afferent  loop  with  silver  wire. 
Lucke  in  1899  advocated  as  an 
improvement  on  Doyen's  method 
an  operation  (Lucke's  second 
method)  which  combined  the 
merits  of  the  Y- operation  with  the 
advantages  of  the  enteroanas- 
tomosis  introduced  by  Braun. 
To  accomplish  this,  Lucke 
divided  the  jejunum  completely 
25  to  40  cm.  (10  to  15  inches) 
from  its  origin,  closed  both 
ends,  and  then  made  two  lateral 
anastomoses — one  between  the 
posterior  gastric  wall  and  the  dis- 
tal segment  of  jejunum,  and  the 
other  between  the  two  segments 
of  the  jejunum,  a  convenient 
distance  below  the  stomach. 
By  this  means  he  avoided  the 
end  to  side  implantations  of 
Roux's  method,  which  he  re- 
garded as  dangerous,  while  at 
the  same  time  he  retained  the 
advantage  of  the  principle  of 
the  Y-anastomosis,  which  rendered  a  simultaneous  entero-anasto- 
mosis unneccessary. 

The  most  valuable  modification  of  all  was  that  introduced  in  1901 
24 


Fig.  55. — Diagram  to  Show  Petersen's 
Method  oe  Gastro-jejunostomy. 


3/0  Technique  of  Operations. 

by  Petersen,  of  Czerny's  clinique;  in  this  operation,  a  posterior  trans- 
mesocoHc  gastro-jejunostomy,  the  afferent  loop  was  abohshed,  the 
anastomosis  in  the  jejunum  being  made  as  close  as  possible  to  the 
duodeno-jejunal  juncture.  This  remains  the  standard  operation,  and 
has  superseded  the  popular  short  loop  method  formerly  taught  by 
Robson,  JNIoynihan,  Scudder,  and  Mayo. 

It  is  our  purpose  to  describe  only  the  following  methods  of  perform- 
ing gastro-jejunostomy:  i.  Anterior  ante-colic  gastro-jejunostomy 
(a)  with  clamps  or  the  Murphy  button;  (b)  with  the  McGraw  elastic 
ligature.  2.  Posterior  trans-mesocolic  gastro-jejunostomy  (a)  with 
long  loop  and  entero- anastomosis;  (b)  without  a  loop.  3.  Roux's 
gastro-jejunostomy  in-Y. 

The  indications  for  the  employment  of  gastro-jejunostomy  have 
been  discussed  in  connection  with  the  various  affections  for  which  it 
may  be  adopted. 

General  Considerations.  The  same  incision  will  suffice  no  mat- 
ter what  method  be  adopted.  That  most  frequently  employed  is  a 
longitudinal  incision  through  the  right  rectus  muscle,  close  to  the  me- 
dian line.  It  should  be  about  four  inches  (10  cm.)  in  length,  extending 
from  below  the  ensiform  process  nearly  to  the  umbihcus.  A  very  care- 
ful examination  should  be  made  of  the  whole  operative  field  before  com- 
mencing the  gastro-intestinal  anastomosis,  since  it  occasionally  happens 
that  some  other  method  than  that  originally  designed  will  be  required 
to  meet  the  condition  found.  Especially  important  is  it  to  determine 
the  extent  of  the  whole  stomach,  for,  as  Moynihan  has  pointed  out, 
neglect  of  this  jjrecaulion  may  result  in  the  surgeon  overlooking  the 
existence  of  an  hour-glass  stomach  with  small  cardiac  pouch.  We 
think  the  preference  of  the  operator  should  always  be  for  a  posterior 
gastro-jejunostomy;  hence  his  next  step  should  l)c  to  determine  whether 
the  posterior  wall  of  the  stomach  is  accessil)k'  through  tlie  transverse 
mesocolon.  Before  ])rocee(hng  with  this  search,  the  entire  skin  sur- 
face surrounding  the  abdominal  incision  should  be  covered  with  hot 
moist  gauze  pads,  in  oi-dci-  lo  ])r()tcct  an)-  viscera  whirli  ma_\'  lia\'c  to  be 
drawn  out  of  the  abdomen.  By  now  drawing  the  great  omentum 
with  its  attached  transverse  colon  into  the  wound,  and  turning  them  up- 
ward on  to  the  hot  gauze  pads  already  placed  o\  cr  tlie  epigastrium  and 


Anterior  Gastro-jejunostomy.  371 

lower  thorax,  the  transverse  mesocolon  is  readily  brought  to  view.  If 
the  stomach  is  densely  adherent  to  the  mesocolon  and  the  pancreas 
it  will  be  impossible  to  withdraw  the  transverse  colon  in  this  way;  but 
even  after  this  manoeuvre  has  been  easily  accomplished,  it  maybe  found 
that  there  is  not  a  sufficient  area  of  healthy  gastric  wall  to  permit  of 
an  anastomosis  being  made  in  its  posterior  surface.  Under  these  cir- 
cumstances the  upper  coil  of  jejunum  should  be  identified  before  re- 
placing the  transverse  colon;  neglect  of  this  precaution  may  result  in 
the  surgeon  subsequently  selecting  the  wrong  coil  of  small  intestine  for 
his  anastomosis.  We  know  of  several  instances  in  which  accom- 
plished operators  have  by  mistake  anastomosed  the  lower  ileum  to  the 
stomach.  Pulling  the  transverse  colon  and  the  attached  great  omen- 
tum, as  already  described,  out  of  the  abdominal  wound,  readily  brings 
into  view  the  primary  coil  of  the  jejunum. 

It  is  important  to  make  the  anastomosis  in  the  pyloric  portion  of 
the  stomach,  so  that  the  new  opening  shall  resemble  the  pylorus  as 
nearly  as  possible  in  its  physiological  action. 

Before  the  gastro- intestinal  anastomosis  is  commenced,  the  surgeon 
should  isolate  by  the  use  of  gauze  packs  the  immediate  structures  in- 
volved, and  all  viscera  outside  of  the  abdomen  must  be  carefully  cov- 
ered with  hot  moist  gauze.  One  piece  of  gauze  should  always  be 
passed  just  beneath  the  site  of  the  proposed  anastomosis,  to  be  with- 
drawn on  its  completion.  Usually,  after  the  posterior  wall  of  the 
stomach  has  been  exposed  through  the  transverse  mesocolon,  it  will 
be  found  possible  to  replace  within  the  abdomen  both  the  transverse 
colon  and  the  stomach  itself,  before  proceeding  with  the  operation. 

Before  beginning  any  operation  in  which  it  is  proposed  to  use  the 
Murphy  button,  its  mechanism  should  be  scrupulously  and  repeatedly 
tested  by  the  surgeon  himself.  The  lumen  of  each  half  of  the  button 
should  be  filled  with  cacao  butter;  this  prevents  escape  of  visceral 
contents,  but  will  be  melted  by  the  heat  of  the  body  a  few  moments 
after  the  anastomosis  has  been  completed  (Hartmann). 

Anterior  Gastro-jejunostomy.  The  primary  loop  of  the  jeju- 
num is  identified  by  withdrawing  the  transverse  colon  from  the  wound, 
and  seeking  the  duodeno-jejunal  juncture  in  the  transverse  mesocolon 
just  to  the  left  of  the  spinal  column.     The  transverse  colon  is  then 


372 


Technique  of  Operations. 


replaced  in  the  abdomen,  and  a  point  on  the  jejunum  is  selected  which 
will  reach  the  anterior  wall  of  the  stomach  without  constricting  the 
transverse  colon.  This  is  usually  40  to  60  cm.  (16  to  24  inches)  below 
the  origin  of  the  jejunum.     It  is  not  necessary,  nor  is  it  desirable,  to 


Fig.  56. — Antekior  Gastko-jkjunostomy  w n  h  riir,  Mrui'iiv  Button. 

split  the  great  omcnlum  up  lo  ihc  tran.s\'erse  colon  so  as  to  render  the 
u.se  of  a  shorter  loo])  ])ossible.  We  prefer  to  make  the  anastomosis 
with  the  "Rooseveh"  clamp,  the  techni([ue  emi)l()ycd  being  the  same 
as  that  described  under  the  heading  of  ])osterior  gastro  jejunostomy 
(p.  377).      If  tlic  Murphy  button  is  to  l)e  used,  a  purse  string  suture 


Anterior  Gastro-jejunostomy.  373 

of  linen  is  inserted  in  a  healthy  portion  of  the  anterior  gastric  wall, 
near  the  greater  curvature,  and  if  possible  in  the  pyloric  portion  of  the 
stomach.  A  similar  purse-string  suture  is  also  applied  to  the  jejunum, 
at  the  point  selected,  opposite  the  mesenteric  attachment.  Each  of 
these  sutures  should  encircle  a  space  just  large  enough  to  permit  of 
the  introduction  of  a  Murphy  button;  the  sutures  should  not  be  tied, 
and  the  ends  should  be  left  long,  to  permit  of  pulling  the  suture  tight 
after  each  half  of  the  button  has  been  introduced. 

After  these  sutures  have  both  been  placed,  an  incision  should  be 
made  in  the  gastric  wall  within  the  circle  formed  by  the  purse-string 
suture,  and  the  male  half  of  the  button,  held  in  the  bite  of  a  hsemo- 
stat,  should  be  quickly  passed  into  the  incision.  The  gastric  suture 
is  then  drawn  tight,  tied,  and  cut  close.  The  jejunum  is  opened 
in  a  similar  manner,  the  female  half  of  the  button  is  passed  into  the 
incision,  is  fixed  by  tying  the  pursestring  suture;  and  then  the  two 
halves  are  approximated  and  pushed  home.  A  few  interrupted 
Lembert  sutures,  or  a  continuous  suture,  may  then  be  introduced 
around  the  margins  of  the  button.  The  gauze  packs  are  then  with- 
drawn, the  viscera  suitably  replaced  in  the  abdomen,  and  the  abdom- 
inal wound  closed. 

It  is  proper  to  note  in  this  place  that  the  Murphy  button  is  no  longer 
approved  by  its  inventor  for  use  in  anterior  gastro-jejunostomy.  While 
it  is  true  that  the  operation  may  be  done  equally  well  by  the  use  of 
clamps  and  suture,  without  a  button,  yet  when  it  is  desired  to  complete 
the  operation  rapidly,  we  believe  no  method  is  so  satisfactory  as  the  use 
of  the  Murphy  button.  And  although  we  employ  the  clamps  when- 
ever possible,  we  have  elected  to  describe  the  use  of  the  Murphy  but- 
ton in  connection  with  anterior  gastro-jejunostomy,  because  that  is 
about  the  only  form  of  gastro-intestinal  anastomosis  in  which  the  sur- 
geon cannot  invariably  dispense  with  such  an  aid.  Murphy  has  modi- 
fied the  button  so  that  an  oval  instead  of  a  circular  opening  may  be 
made;  but  we  have  had  no  personal  experience  with  this  newer  form. 

Some  surgeons  prefer  to  use  the  elastic  ligature  introduced  in 
1884  by  J.  McFadden  Gaston,  who  used  it  in  experiments  on  dogs, 
and  which  has  been  proved  to  be  practicable,  and  has  been  popularized 
by  McGraw.     By  its  use  the  actual  time  consumed  in  completing  the 


374  Technique  of  Operations. 

operation  has  been  very  much  reduced.  McGraw  reported  that  it 
took  him  only  three  minutes  to  accomphsh  the  gastro-intestinal  anas- 
tomosis by  the  use  of  his  rubber  ligature.  The  Mayos,  Murphy,  and 
Ochsner,  have  also  spoken  favourably  of  this  method.  The  two 
chief  objections  to  it,  as  stated  by  Alfred  H.  Gould  are  (i)  that  the 
elastic  ligature  does  not  free  itself  by  pressure  necrosis  until  after  the 
lapse  of  from  three  to  five  days,  during  which  time  no  benefit  can  be 
obtained  from  the  gastro-intestinal  anastomosis;  and  (2)  that  through 
certain  errors  in  technique  the  anastomosis  may  be  irregular  in  out- 
line, or  the  ligature  may  not  cut  entirely  through. 

The  rubber  ligature,  according  to  Gould,  may  be  obtained  in  three 
sizes:  large,  5  mm.  in  diameter;  medium,  4  mm.;  small,  3  mm.  (one- 
fifth  to  one-eighth  of  an  inch).  Gould  states  that  the  medium  is  the 
preferable  size,  because,  although  it  does  not  cut  through  as  quickly 
as  the  larger  size,  it  is  more  elastic.     Ochsner  uses  the  small  size. 

The  McLean  needle  is  to  be  preferred  for  introducing  the  rubber 
ligature.  This  needle  is  provided  with  a  large  eye  in  its  blunt  end,  the 
eye  being  open  on  one  side,  like  that  of  the  Reverdin  needle  when  its 
slide  is  withdrawn.  Into  this  open  eye  the  ligature  is  passed,  being 
stretched  until  it  is  small  enough  to  enter  easily.  A  ferrule  is  then 
slid  down  over  the  end  of  the  ligature. 

The  technique  of  the  application  of  the  rubber  ligature  is  as 
follows : 

No  clamps  are  necessary,  as  the  viscera  to  be  anastomosed  are  not 
opened  during  the  operation.  Placing  the  coil  of  jejunum  selected 
against  the  stomach,  a  posterior  layer  of  Lembcrt  sutures  is  introduced, 
as  in  ordinary  methods  of  lateral  anastomosis.  McGraw  prefers  an 
interrupted  suture.  At  least  three  inches  (7.5  cm.)  of  stomach  and  in- 
testine should  be  united  in  this  manner.  By  now  pinching  the  stom- 
ach up  into  a  fold  transverse  to  its  long  axis,  the  needle  may  be  made 
to  pcnclralc  the  base  of  this  fold  (aljoul  1  cm.  from  the  line  of  sutures), 
and,  while  the  rubber  ligature  is  stretched  until  its  diameter  becomes 
less  than  that  of  the  needle,  the  latter  is  withdrawn  on  the  far  side  of 
the  fold  of  gastric  wall.  As  this  fold  llattens  out,  it  will  be  seen  that 
the  two  punctures  liave  Ix-en  made  at  points  two  or  three  inches  apart, 
and  that  as  a  consefjuence  the  rubber  ligature  ])asses  for  that  distance 


Elastic  Ligature  in  Gastro-jejunostomy. 


-ijs 


within  the  cavity  of  the  stomach.  The  jejunum  is  then  pinched  up  into 
a  fold  of  similar  size,  the  base  of  the  fold  is  transfixed  by  the  needle 
(but  in  the  reverse  direction),  and  when  the  elastic  ligature  emerges 
again  opposite  its  starting  point,  it  is  there  knotted. 

It  is  very  important  to  make  sure  that  the  needle  has  really  en- 
tered the  lumen  of  the  stomach  and  bowel,  since  in  some  reported 
cases  the  needle  merely  dissected  the  mucosa  free  from  the  muscular 
wall  without  entering  the  cavity  of  the  intestine  or  the  stomach 
except  for  a  very  short  dis- 
tance. 

To  prevent  the  knot  in  the 
rubber  ligature  from  slipping 
it  is  important  to  fix  each  half 
of  the  knot  by  tying  around 
it  a  strand  of  silk  or  linen. 
Great  care  must  be  taken  not 
to  let  the  line  of  the  primary 
sero-serous  sutures  slip  into 
the  grasp  of  the  rubber  liga- 
ture as  it  is  drawn  taut. 

Finally  the  posterior  row  of 
sero-serous  sutures  is  continued 
around  the  site  of  the  anasto- 
mosis, which  is  considerably 
puckered  up  by  tying  the  elastic 
ligature.  This  completes  the 
operation;  and  the  newly 
formed  channel  will  be  opened 

in  a  few  days  by  the  sloughing  produced  by  the  constriction  of  the 
elastic  ligature.  Murphy  found  that  this  sloughing  occurred  fastest 
at  the  point  constricted  by  the  knot  of  the  rubber  ligature,  and  hence 
advises  making  another  half  knot  at  the  other  end  of  the  proposed 
anastomosis;  of  course,  as  this  knot  cannot  be  pulled  through  the 
lumen  of  the  intestine,  it  is  necessary,  in  using  this  technique,  to  have 
the  ligature  threaded  at  both  ends. 

Posterior  Gastro-jejunostomy.     (A).     Long  Loop. — The  trans- 


FiG.  57. — Diagram  to  show  Use  of  the 
Elastic  Ligature  of  McGraw. 


11^ 


Technique  of  Operations. 


verse  colon  and  the  attached  omentum  are  drawn  out  of  the  wound, 
and  by  puhing  these  structures  upward  and  to  the  patient's  right  the 
transverse  mesocolon  is  put  upon  the  stretch  and  the  origin  of  the 
jejunum  brought  into  sight.  Selecting  now  a  bloodless  area  to  the 
left  of  the  main  trunk  of  the  middle  colic  artery,  the  transverse  meso- 


FiG.  58.— Picking  up  the  Prlmary  Loop  of  the  Jejunum.    The  Transverse 
Mesocolon  has  been  Incised  to  the  Left  of  the  Middle  Colic  Artery. 

colon  is  here  torn  through  with  dissecting  forceps,  and  the  opening 
enlarged  in  the  sagittal  i)lane,  by  the  lingers  or  Ijy  a  few  snips  with 
scissors,  until  it  is  about  three  or  four  inches  (7.5  to  lo  cm.)  in 
length.  The  left  hand  of  the  oi)erator,  which  holds  the  transverse 
colon  between  finger  and  thumb,  the  fmgers  being  on  the  upj^cr  sur- 


Posterior  Gastro-jejunostomy.  377 

face,  can  now  make  the  posterior  gastric  wall  protrude  into  this 
opening  in  the  transverse  mesocolon.  It  will  usually  be  found  that  the 
portion  of  the  gastric  wall  thus  brought  to  view  is  that  immediately  be- 
neath the  cardiac  orifice,  and  that  it  is  quite  close  to  the  greater  curva- 
ture of  the  stomach.  One  pair  of  gastro-enterostomy  clamps,  its 
blades  sheathed  in  rubber  tubing,  is  then  applied  to  the  posterior  gas- 
tric wall,  holding  in  its  grasp  a  generous  fold  of  the  stomach,  so  as 
to  allow  plenty  of  room  for  the  application  of  the  sutures.  The  base 
of  the  fold  of  gastric  wall  thus  grasped  should  be  at  least  three  inches 
(7.5  cm.)  in  length  and  the  portion  grasped  should  be  in  the  pyloric 
antrum,  not  in  the  body  or  fundus  of  the  stomach.  The  direction  in 
which  the  forceps  are  placed  is  immaterial;  as  a  rule  they  should  be 
placed  more  or  less  parallel  to  the  greater  curvature  of  the  stomach. 
The  primary  loop  of  the  jejunum  is  now  brought  forward,  and  a  point 
about  ten  inches  (25  cm.)  from  its  origin  is  selected  for  the  anastomosis. 
The  bowel  is  grasped  in  the  other  pair  of  rubber  covered  forceps  for 
an  equal  distance,  about  three  inches  (7.5  cm.).  A  small  piece  of  gauze 
is  then  laid  beneath  the  parts  to  be  approximated,  and  the  clamps  are 
placed  side  by  side  in  front  of  this  gauze,  with  the  coil  of  the  jejunum 
in  an  iso-peristaltic  direction.  (Dr.  Deaver  usually  employs  a  three- 
bladed  clamp,  known  as  the  "Roosevelt.")  The  transverse  colon  and 
all  the  viscera  not  immediately  concerned  in  the  anastomosis  are  then 
replaced  inside  the  abdomen,  and  the  entire  operative  field  is  isolated 
by  sterile  gauze.  The  stomach  and  the  jejunum,  which  are  main- 
tained in  apposition  by  an  assistant  who  holds  the  two  pairs  of  clamps, 
are  now  to  be  united  by  a  posterior  sero-serous  continuous  suture  of 
linen  thread.  This  suture  should  be  applied  as  close  as  possible  to 
the  blades  of  the  clamps,  so  as  to  leave  plenty  of  room  for  the  through- 
and-through  sutures.  The  posterior  row  of  sutures  should  commence 
a  little  beyond  one  extremity  of  the  proposed  anastomosis,  and  is  to 
be  continued  a  little  past  the  other  end,  where  it  may  be  knotted  to 
prevent  puckering  of  the  anastomosis  (as  advised  by  Hartmann). 
The  ends  of  this  suture  should  be  left  long,  and,  with  the  needle  still 
threaded,  it  should  be  laid  aside  and  covered  with  sterile  gauze  until 
again  needed. 

An  incision  about  two  and  a  half  inches  (6  cm.)  long  is  now  made 


37^  Technique  of  Operations. 

with  a  scalpel  through  the  serous  and  muscular  coats  of  the  stomachy 
about  one  centimetre  (approximately  one-third  of  an  inch)  distant  from 
the  continuous  suture  just  inserted.  When  the  mucous  layer  of  the 
gastric  wall  is  thus  exposed,  it  will  pout  a  little  into  the  incision;  it  is 
then  to  be  picked  up  with  forceps  and  cut  off  with  scissors,  flush  with 
the  margins  of  the  incision.  The  gastric  secretions  should  be  wiped 
away,  and  when  the  incision  in  the  stomach  is  dry,  the  jejunum  should 
be  opened  in  a  similar  manner,  and  for  an  equal  distance;  less  of  the 
mucosa  of  the  jejunum  than  of  the  stomach  will  prolapse,  and  it  is 
not  always  necessary  to  excise  it.  All  the  instruments  which  have 
come  into  contact  with  the  gastric  or  intestinal  contents  should  now 
be  discarded. 

The  surgeon  now  has  the  cavity  of  the  stomach  and  that  of  the 
jejunum  opened,  and  a  posterior  sero-serous  suture  applied.  He 
should  next  unite  the  adjacent  free  edges  of  these  viscera  by  a  through- 
and-through  continuous  suture  of  chromicised  (or  iodized)  catgut. 
Beginning  at  one  extremity  of  the  incisions  into  stomach  and  jejunum, 
the  needle  is  passed  from  the  mucous  surface  of  the  jejunum  through 
its  wall  to  its  serous  surface,  and  from  the  serous  surface  of  the  stomach 
into  the  cavity  of  the  latter.  The  suture  is  then  fixed  by  knotting  it; 
and  by  continuing  to  suture  in  a  precisely  similar  manner  the  poste- 
rior margins  of  the  incisions  arc  united  from  one  extremity  to  the  other. 
The  suture  may  be  knotted  from  time  to  time  if  desired,  to  prevent 
puckering,  as  taught  by  Hartmann ;  usually  this  is  unnecessary.  When 
the  surgeon  reaches  the  end  of  the  posterior  margins  of  the  gastric  and 
jejunal  incisions,  he  should  continue  his  suture  carefully  around  the 
end,  and  begin  the  approximation  of  their  anterior  margins.  As 
these  arc  not  held  in  close  apposition  by  the  clamps,  as  were  the  pos- 
terior margins,  it  is  a  little  difficult  at  first  to  understand  how  to  con- 
tinue the  suture  so  as  to  secure  the  approximation  of  serosa  to  serosa. 
If  the  surgeon,  however,  pursues  precisely  the  same  method  already 
adoj^ted,  he  will  have  no  trouble  with  this  part  of  the  operation;  he 
should  pass  his  needle  from  the  mucous  surface  of  the  jejunum  to  its 
serous  surface,  then  from  the  serous  surface  of  the  stomach  to  its 
mucous  surface,  draw  the  stitch  tight,  and  repeat  the  process.  To  put 
it  briefly,  the  needle  is  passed  out,  in,  and  over ;  out,  in,  and  over ;  etc. 


Posterior  Gastro-jejunostomy.  379 

— that  is  to  say,  out  of  one  organ,  into  the  other,  and  over  the  Kne  of 
sutures,  to  again  pass  out  of  the  jejunum,  into  the  stomach,  and  across 
the  suture  hne  back  to  the  starting  point.  By  drawing  each  stitch 
fairly  tight,  it  is  easy  to  determine  the  point  where  the  needle  should 
next  be  inserted.  About  four  or  five  stitches  should  be  made  to  every 
inch.  When  the  entire  circumference  of  the  anastomosis  has  been 
united  by  this  through-and-through  suture,  the  catgut  thread  is  tied 
to  its  own  original  end,  at  the  starting  point,  and  cut  short.  The 
sero-serous  suture,  previously  laid  aside,  is  now  to  be  resumed,  re- 
inforcing the  anastomosis  on  its  anterior  aspect,  and  completing  the 
circumference  of  the  wound  to  its  starting  point,  where  it  is  to  be 
tied  to  its  own  initial  extremity  and  cut  short. 

It  is  usually  advisable,  so  soon  as  the  through-and-through  sutures 
have  been  completed,  and  all  danger  of  contamination  from  gastric 
or  intestinal  contents  has  been  thus  eliminated,  to  release  the  rubber 
covered  clamps ;  for  it  is  not  desirable  to  keep  them  in  place  too  long, 
as  there  is  always  a  possibility  of  long  continued  pressure  injuring  the 
gastric  or  intestinal  walls.  It  is  convenient,  however,  to  keep  one 
blade  beneath  the  anastomosis,  as  a  sort  of  bridge  to  hold  the  viscera 
in  place,  until  the  anterior  sero-serous  sutures  have  been  completed 
(Munro).  Any  bleeding  points  observed  when  the  clamps  are  re- 
moved, should  be  caught  up  in  special  sutures. 

When  the  gastro-intestinal  anastomosis  has  been  finished  in  this 
manner,  the  surgeon  should  thoroughly  rinse  his  gloved  hands  in  cor- 
rosive sublimate  and  then  in  sterile  water.  It  is  often  better  to  put 
on  another  pair  of  sterile  gloves. 

The  edges  of  the  opening  in  the  mesocolon  are  next  to  be  sutured 
to  the  gastric  wall  a  short  distance  away  from  the  anastomosis.  This 
is  a  very  important  step  in  the  operation,  and  should  never  be  for- 
gotten. It  prevents  prolapse  of  coils  of  small  bowel  into  the  lesser 
peritoneal  cavity,  and  also  keeps  the  mesocolon  from  constricting  the 
anastomosis  itself  or  from  slipping  do\\'n  over  the  afferent  and  efferent 
loops  of  jejunum  and  thus  causing  obstruction.  It  is  well  to  place  a 
stitch  at  each  extremity  of  the  opening  in  the  mesocolon  to  keep  the 
incision  from  tearing  larger.  It  is  also  the  custom  of  the  senior  author 
to  insert  an  "anchor  suture"  to  hold  the  jejunal  loop  in  contact  with  the 


38o 


Technique  of  Operations. 


gastric  wall  at  the  jejunal  end  of  the  anastomosis  so  as  to  prevent 
kinking  of  the  jejunal  loop  by  sagging. 

The  gauze  surrounding  the  field  of  operation  is  now  to  be  removed ; 
as  that  piece  of  gauze  immediately  underlying  the  anastomosis  is  drawn 
out  it  will  rotate  the  anastomosed  structures  far  enough  to  enable 


Fig.  59. — PosTKRiOR  Gastro-jeju.nostomy  with  Kntero-anastomosis.     For  Sim- 
plicity THE  Rubber-covered  Clamps  are  not  Shown. 


the  surgeon  to  ins])e(t  the  posterior  line  of  sutures,  and  lluis  to  assure 
himself  that  all  is  in  good  rondilion  on  that  surface  of  the  anastomosis. 
If  no  entcro-anastomosis  is  to  be  done,  the  viscera  arc  carefully 
replaced  in  the  alxlomcn,  the  great  omentum  is  drawn  down  over  the 
small  intestines,  and  tin-  abdominal  wound  is  closed. 


Posterior  Gastro-jejunostomy.  381 

Entero-anastomosis  may  be  accomplished  by  the  use  of  clamps 
by  precisely  the  same  technique  of  lateral  anastomosis  as  that  just 
described  for  gastro-jejunostomy;  or  a  Murphy  button  or  the  McGraw 
elastic  ligature  may  be  used,  if  it  should  seem  desirable  to  hasten  the 
operation.  The  anastomosis  should  be  made  between  the  afferent 
and  efferent  loops  of  jejunum  about  10  cm.  (four  inches)  below  the 
gastro-intestinal  anastomosis. 

Remarks.  We  have  described  posterior  gastro-jejunostomy  with 
the  use  of  a  long  loop  because  it  is  important  for  the  surgeon  thor- 
oughly to  understand  the  technique  of  the  operation,  in  order  that  he 
may  be  qualified  to  treat  the  complications  which  sometimes  follow 
its  employment.  We  have  ourselves  entirely  abandoned  this  form  of 
operation,  because  we  believe  that  the  "no  loop"  method  gives  much 
better  and  much  more  certain  results;  but  operations  with  a  "long 
loop"  have  been  done  in  the  past,  and  even  now  any  surgeon  is  liable 
to  be  called  upon  at  any  time  to  treat  patients  suffering  from  the 
vicious  circle  following  gastro-jejunostomy  by  this  method,  employed 
a  number  of  years  previously,  perhaps  by  another  operator.  We 
believe  primary  entero-anastomosis  is  always  advisable  when  the  long 
loop  method  is  employed,  and  think  it  safer  to  use  the  clamps  and 
sutures  rather  than  any  appliance  such  as  the  Murphy  button. 

(B)  No  Loop.  The  transverse  colon  is  delivered  in  the  manner 
already  described,  and  the  transverse  mesocolon  opened,  and  the  pos- 
terior wall  of  the  stomach  exposed  precisely  as  in  the  technique  em- 
ployed when  a  long  jejunal  loop  is  used.  The  clamps,  however, 
should  not  be  applied  parallel  to  the  greater  curvature  of  the  stomach, 
since  to  do  so  would  markedly  distort  the  jejunum,  which  at  its  origin 
runs  more  or  less  perpendicularly  to  the  greater  curvature  of  the 
stomach.  Instead,  the  gastric  clamp  is  to  be  applied  a  little  obliquely, 
so  that  the  incision  in  the  stomach  will  pass  from  above  downward 
and  to  the  patient's  right.  Mayo  has  urged  that  the  incision  be  made 
in  the  other  direction,  obliquely  downward  and  to  the  left,  claiming 
that  this  preserves  the  normal  anatomical  relations  better,  and  that 
the  fact  of  the  anti-peristaltic  direction  of  the  anastomosis  thus  effected 
is  of  no  consequence.  But  as  Moynihan  points  out,  the  jejunum 
is  quite  freely  movable  below  the  ligament  of  Treitz,  and  if  found 


382 


Technique  of  Operations. 


running  downward  and  to  the  left  while  patients  are  on  their  backs, 
may  also  be  found  running  downward  and  to  the  right  if  they  are 
made  to  he  on  their  right  side.  Therefore  it  seems  best  to  adhere  to 
the  method  of  Petersen,  who  made  the  opening  in  the  stomach  prac- 
tically at  right  angles  to  its  greater  curvature,  or  perhaps  inclined  a 
little  to  the  right.  Moynihan  lays  stress  on  the  importance  of  not 
rotating  the  jejunum  on  its  long  axis,  as  this  may  cause  obstruction 
at  the  duodeno-jejunal  flexure.  Latterly  we  have  made  the  anasto- 
mosis with  the  jejunal  loop  inclined  to  the  patient's  left,  and  have 

seen  no  ill  effects  from  it. 
The  point  of  emerg- 
ence of  the  jejunum  from 
the  transverse  mesocolon 
corresponds  in  most  in- 
stances very  closely  to  the 
duodeno-jejunal  junc- 
ture; but  in  a  small  pro- 
portion of  cases  the  jeju- 
num is  retro-peritoneal 
for  a  variable  distance 
from  its  origin  before 
leaving  the  posterior  pa- 
rietal peritoneum  and 
becoming  invested  by  the 
mesentery.  Alurphy  has  described  a  retro-peritoneal  position  of  the 
primary  loop  of  jejunum,  several  inches  in  length,  which  he  claims 
to  have  encountered  lately  in  a  numljcr  of  patients.  Mayo  has  also 
called  attention  to  the  occasional  presence  of  a  peritoneal  fold  which, 
passes  from  the  transverse  mesocolon  for  some  distance  down  the 
jejunum.  It  is  important  for  the  surgeon,  therefore,  critically  to 
examine  the  sup]K)sed  primary  coil  of  jejunum,  and  to  make  sure  that 
no  abnormality  will  cause  him  to  perform  a  long  loop  operation  when 
he  aims  to  leave  no  loop  at  all.  If  the  peritoneal  fold  described  by 
Mayo  is  recognized,  it  should  \)v  dix-idcd  up  to  its  origin  in  the  trans- 
verse mesocolon,  the  raw  area  left  on  the  jejunum  should  be  inverted 
by  a  few  sutures,  and  the  anastomosis  made  close  to  the  true  origin  of 


Fig.    6o. — Posterior  Gastro-jejunostomy  with 
NO  Jejunal  Loop. 


Posterior  Gastro-jejunostomy.  383 

the  jejunum.  If  the  first  coil  of  jejunum  be  retro-peritoneal,  as  des- 
cribed by  Murphy,  it  may  not  be  possible  to  employ  it  for  the  anas- 
tomosis. Hence  the  surgeon  will  be  forced  to  perform  a  long  loop 
gastro-jejunostomy;  and  he  will  do  well  under  such  circumstances  to 
safeguard  this  by  an  entero-enterostomy  as  described  in  the  previous 
section. 

In  case  no  abnormality  exists,  the  rubber  covered  clamps  are  ap- 
plied to  the  posterior  gastric  wall  and  to  the  jejunum,  as  previously 
described,  except  that  no  loop  of  jejunum  is  left;  and  the  anastomosis 
is  completed  in  the  same  way.  It  is  important  that  the  anastomosis 
should  be  made  in  the  pyloric  antrum,  so  as  to  allow  it  to  approach 
as  closely  as  possible  in  physiological  action  to  the  normal  pylorus. 
It  is  well  to  bear  in  mind  that,  inasmuch  as  the  stomach  is  turned  up- 
side down  during  the  operation,  the  clamps  are  to  be  applied  with  their 
axis  running  from  the  patient's  right  shoulder  toward  his  left  hip,  and 
not  in  a  direction  from  his  left  shoulder  to  his  right  hip.  With  the 
clamps  lying  in  the  latter  direction  the  opening  in  the  stomach  will  be 
made  obliquely  dovmward  and  to  the  patient's  left. 

After  the  gastro-jejunal  anastomosis  has  been  completed,  the  mar- 
gins of  the  opening  in  the  mesocolon  are  sutured  to  the  posterior 
wall  of  the  stomach  around  the  anastomosis,  one  "anchor  suture" 
is  inserted,  as  described  at  page  379,  and  the  viscera  are  then  replaced 
in  their  normal  positions.  The  great  omentum  is  finally  drawn  care- 
fully down  over  the  small  intestine,  and  the  abdominal  wound  closed 
in  the  usual  way. 

Posterior  Gastro-jejunostomy  in-Y  (Roux) .  Deliver  the  trans- 
verse colon,  incise  the  mesocolon,  and  expose  the  posterior  wall  of  the 
stomach,  as  already  described,  and  apply  a  rubber  covered  clamp,  in 
the  usual  way.  Draw  out  of  the  abdomen  the  first  coil  of  the  jejunum, 
and  empty  it  of  its  contents  by  manipulation  with  the  fingers  for  a 
distance  of  about  twelve  inches  (30  cm.).  Apply  a  long  rubber 
covered  clamp  across  its  lumen  in  two  places,  leaving  an  omega  loop 
of  at  least  ten  inches  (25  cm.),  with  its  mesentery,  hanging  free 
beyond  the  clamp.  Or  if  it  seems  undesirable  to  clamp  the  entire 
blood  supply  for  so  long  a  time,  the  surgeon  may  employ  two  smaller 
clamps,  each  constricting  the  entire  lumen  of  the  jejunum,  about 


384  Technique  of  Operations. 

25  cm.  (10  inches)  distant  one  from  the  other.  The  proximal  point 
of  the  jejunum  clamped  should  be  about  10  inches  (25  cm.)  below 
the  duodcno-jejunal  juncture.  Next  divide  the  jejunum  completely 
across  about  four  inches  (10  cm.)  below  where  the  clamp  compresses 
its  proximal  end.  This  will  leave  two  segments  of  jejunum  within 
the  grasp  of  the  clamp:  the  proximal  segment  will  be  about  four 
inches,  and  the  distal  about  six  inches  long.  An  incision  is  then 
made  in  the  portion  of  the  posterior  wall  of  the  stomach  which  is 
held  in  the  grasp  of  the  other  pair  of  rubber  covered  clamps,  and  the 
pouting  mucous  membrane  is  excised.  Then  the  surgeon  unites  by 
termino-lateral  implantation  the  open  circular  end  of  the  distal  jeju- 
nal loop  with  the  gastric  incision,  applying  first  a  posterior  sero-serous 
suture,  then  a  through-and-through  haemostatic  suture,  which  passes 
entirely  around  the  anastomosis;  and  finally  the  posterior  sero-serous 
suture  is  resumed,  re-inforcing  the  gastro-intestinal  anastomosis  on 
its  anterior  aspect.  Then  an  incision  is  made  in  the  distal  segment 
of  jejunum  opposite  the  mesenteric  attachment,  about  an  inch 
(2.5  cm.)  from  the  point  where  it  is  clamped,  and  the  proximal 
segment  is  implanted  into  this  incision,  in  precisely  the  same  manner 
ftermino-lateral  anastomosis)  as  that  in  which  the  jejunum  has  just 
been  united  to  the  stomach.  The  clamps  may  now  be  removed. 
If  the  gastric  clamp  be  removed  before  the  second  anastomosis  is 
completed  there  will  be  danger  of  leakage  of  gastric  contents  through 
the  lateral  incision  made  in  the  jejunum  for  the  jcjuno-jejunal 
anastomosis. 

Before  closing  the  wound,  the  structures  should  be  carefully  ar- 
ranged in  the  abdomen;  and  the  surgeon  should  not  neglect  to  suture 
the  transverse  mesocolon  to  the  stomach  around  the  gastro-jcjunal 
anastomosis. 

Exclusion  of  the  pylorus  was  proposed  in  1895  by  v.  Eiselsberg, 
and  cmjjloycd  by  liim  in  four  cases.  The  o])eration  consists  in  divid- 
ing the  stomach  cf)m])]clely  in  the  ])rc-])yl()ric  region,  closing  both  ends 
by  suture,  and  then  ])('rr()rn"iing  posterior  gastro-jejunostomy.  Jon- 
nesco  prefers  this  form  of  oj)eration  to  a  simple  gastro-enterostomy, 
and  always  employs  it  when  excision  (pylorcctomy;  partial  gastrec- 
tomy) is  impossible.     He  reports  9  operations  by  this  method  during 


Exclusion  of  the  Pylorus.  385 

1906-1907,  with  8  patients  cured,  and  one  patient  dying  on  the  eighth 
day  from  hemorrhage  from  a  gastric  ulcer. 

We  have  already  expressed  our  preference  for  simple  gastro-jejun- 
ostomy  instead  of  excision  or  partial  gastrectomy  unless  there  is  a  sus- 
picion of  the  disease  being  malignant;  and  we  cannot  see  that  this 
operation  of  exclusion  of  the  pylorus  presents  any  particular  advan- 
tages in  ordinary  cases.  When  the  pylorus  is  freely  patulous,  there 
will  be  a  tendency  for  the  gastric  ulcers  to  heal  when  the  acidity  of  the 
gastric  secretions  shall  have  been  diminished  by  gastro-jejunostomy; 
but  exclusion  of  the  ulcerated  area  from  the  stomach  would  prevent 
this  change  in  the  gastric  secretions  having  any  effect  on  the  ulcers, 
while  at  the  same  time  it  would  subject  the  patients  to  very  nearly  as 
much  danger  as  would  a  pylorectomy.  Possibly  in  a  patient  with 
tuberculous  ulcers  of  the  pyloric  region  exclusion  of  the  pylorus  might 
be  preferable  to  gastro-jejunostomy  were  pylorectomy  impossible. 


25 


386 


Technique  of  Operations. 


Fig.  6i. — Diagram  of  Incisions  for  (i) 
Gastroplasty;    (2)     Gastro-anas- 

TOMOSIS. 


GASTROPLASTY. 

Gastroplasty,  an  operation  analogous  to  pyloroplasty,  is  adopted 
in  certain  cases  of  hourglass  constriction  of  the  stomach.  This  oper- 
ation is  said  to  have  been  employed  first  by  Bardeleben,  in  1889.    The 

first  patient  who  recovered  was 
operated  upon  in  1892  by  Kruken- 
berg. 

A  rubber  covered  clamp  is 
applied  to  the  stomach,  with  its 
axis  corresponding  to  the  long 
axis  of  this  organ,  so  as  to  pick 
up  in  its  grasp  a  fold  of  gastric 
wall  forming  the  channel  of 
communication  between  the  two 
pouches  of  the  stomach.  This 
fold  of  gastric  wall  is  then  incised  down  to  the  mucous  coat,  which  is 
excised  when  it  pouts  into  the  incision.  Haemostatic  or  Alhs's  forceps 
are  then  used  to  grasp  the  margins  of  the  gastric  incision  at  its  ex- 
tremities and  at  the  mid-point  of 
each  of  its  sides.  As  these  for- 
ceps draw  the  gastric  incision  well 
upward,  the  clamp  is  loosened, 
removed,  and  reapplied  at  right 
angles  to  its  former  position.  As 
this  is  done  the  pairs  of  forceps 
formerly  at  the  mid-points  of  the 
gastric  incision  are  separated  so 
as  to  change  the  formerly  longi- 
tudinal incision  into  a  transverse 

wound,  while  the  forceps  formerly  at  the  ends  of  tlic  incision  will  now 
be  attached  to  its  sides.  The  rubber  covered  clamp  having  been  re- 
applied,   the   gastric   incision   is   closed   by   a   through-and-through 


Fig.  ()2 


-Gastroplasty. 


Gastro-anastomosis.  387 

haemostatic  suture  of  iodized  catgut,  which  is  afterward  reinforced  by 
a  continuous  Lembert  suture  of  hnen.  The  rubber  covered  clamps 
should  be  loosened  as  soon  as  the  through-and-through  suture  has 
been  completed,  to  test  its  haemostatic  effect;  and,  as  in  other  opera- 
tions, any  bleeding  points  should  be  controlled  by  separate  sutures. 


GASTRO-GASTROSTOMY. 
Gastro-gastrostomy,  an  operation  first  employed  in  cases  of 
hour-glass  stomach  by  Wolfler  in  1894,  consists  in  making  a  lateral 
anastomosis  between  the  adjacent  parts  of  the  gastric  pouches.  Two 
rubber  covered  clamps  are  applied  to  the  stomach,  one  in  the  cardiac, 
the  other  in  the  pyloric  pouch,  lying  parallel  to  each  other  and  trans- 


FiG.  63. — Gastro-gastrostomy.  Fig.  64. — Gastro-anastomosis. 

verse  to  the  long  axis  of  the  stomach.  The  usual  technique  of  lateral 
anastomosis  by  suture  is  followed.  The  opening  should  be  at  least 
three  inches  long.  If  the  form  of  the  constriction  prevents  so  large 
an  anastomosis,  some  other  operation  should  be  employed. 

GASTRO-ANASTOMOSIS. 
Gastro-anastomosis.  This  term  may  be  used  to  designate  an 
operation  for  hour-glass  stomach  analogous  to  Finney's  pyloroplasty, 
introduced  in  1903  by  Kammerer.  Clamps  may  be  used  for  this 
operation,  which  differs  from  gastro-gastrostomy  only  in  that  the 
incisions  meet,  becoming  continuous  one  with  the  other  through  the 
anterior  wall  of  the  channel  connecting  the  two  gastric  pouches. 


388 


Technique  of  Operations. 


GASTRO-PLICATION. 

Gastro-plication.  This  operation,  proposed  in  1891  by  Bircher, 
is  now  usually  clone  by  Moynihan's  modification  of  Bennett's  method. 
Interrupted  Lembert  sutures  are  placed  in  the  anterior  gastric  wall, 
each  suture  picking  up  this  structure  in  four  or  five  places,  and  running 


Fig.    65. — G.A.STRO-PLICATION. 


Fig.  66. — Gastro-plication,  seen  in 
Sagittal  Section. 


from  the  greater  to  the  lesser  curvature,  transversely  to  the  long  axis 
of  the  stomach.  As  these  sutures  arc  tightened,  the  anterior  wall 
of  the  stomach  is  j^uckered  up,  and  the  curvatures  approach  each 
other,  thus  diminisliing  the  capacity  of  the  stomach. 


(tASTROPKXY. 

Gastropexy,  an  operation  designed  to  fix  a  proptoscd  stomach, 
may  ];e  ])erformed  by  cither  Buret's  or  Bcyca's  method. 

(i)  Buret's  Methock  I'he  abdomen  is  opened  through  the  left 
rectus  muscle,  but  the  jjarietal  jjcritoneum  in  the  upper  portion  of  the 
wound  is  not  divided.     By  interrupted  or  continuous  Lembert  sutures 


Gastropexy.  389 

of  linen  the  anterior  gastric  wall  is  sutured  to  the  parietal  peritoneum 
of  the  epigastric  region.  The  sutures  should  be  inserted  near  the 
lesser  curvature  of  the  stomach,  and  should  include  not  only  the 
peritoneum  of  the  abdominal  wall  but  also  the  muscle  and  overlying 
fascia.  They  should  not,  however,  pass  through  the  skin,  as  it  is 
desirable  that  they  should  remain  permanently. 

(2)  Beyea's  Method.  Interrupted  sutures  of  linen  are  passed 
through  the  gastro-hepatic  omentum  from  the  stomach  up  to  the  under 
surface  of  the  liver;  each  suture  picks  up  the  lesser  omentum  in  four 
or  five  places.  As  these  sutures  are  tightened  the  lesser  curvature  of 
the  stomach  is  drawn  up  against  the  liver  by  the  puckering  of  the 
gastro-hepatic  omentum.  Care  should  be  taken  not  to  puncture  any 
blood-vessels  in  this  structure. 


390 


Technique  of  Operations. 


GASTRECTOMY. 


Gastrectomy.  The  terminology  employed  by  writers  with  re- 
gard to  excision  of  portions  of  the  stomach  is  not  always  uniform,  and 
unless  the  terms  used  are  clearly  defined  confusion  is  liable  to  arise. 
In  the  present  work  we  employ  the  following  terms  to  designate  the 
operations  denoted  below.  Sphlncterectomy :  By  this  we  understand 
the  removal  merely  of  the  pyloric  sphincter,  with  end-to-end  reunion 
of  the  duodenum  and  the  stomach.  It  is  an  operation  which  in  a  few 
rare  instances  has  been  employed  for  benign  fibrous  stenosis  of  the 

pylorus,  in  which  the  pre-pyloric 
portion  of  the  stomach  was 
healthy.  Pyloroplasty,  we  think, 
would  be  a  less  dangerous  and 
quite  as  satisfactory  an  opera- 
tion. By  Pylorcciomy  we  mean 
removal  of  the  pylorus;  it  is  a 
more  extended  resection  than 
sphincterectomy,  but  less  so  than 
partial  gastrectomy,  in  which 
latter  operation  the  entire  lesser 
curvature  of  the  stomach  is  re- 
moved. It  is  not  always  possible 
during  an  operation  to  determine  the  precise  limits  of  the  pyloric 
antrum;  but,  in  general,  we  mean  by  partial  gastrectomy  an  operation 
which  removes  besides  the  pylorus,  also  the  neighbouring  part  of  the 
stomach  as  far  as  the  Hartmann  or  Mikulicz  line,  always  including  the 
whole  of  the  lesser  curvature.  If  the  gastric  area  removed  extends 
still  further  toward  the  fundus  along  the  greater  curvature,  we  speak 
of  the  operation  as  subtotal  gastrectomy;  while  the  term  total  gastrectomy 
is  reserved  for  operations  which  leave  behind  no  portion  of  the  stomach, 
the  upper  section  passing  through  the  lower  end  of  the  ocso])hagus, 
while  the  lower  section  of  course  divides  the  duodenum.     Circular  or 


Fig.  67. — Diagram  Showing  Various  In- 
cisions FOR  Gastrectomy. 
G,  Duodenal  section;  AB,  Hartmann  line; 

AC,  Mikulicz  line;    AD,  Mayo   line; 

AE,  total  gastrectomy. 


Pylorectomy.  391 

cylindrical  gastrectomy  designates  an  operation  by  which  the  central 
portion  of  the  stomach  is  removed,  neither  the  pylorus  nor  the  fundus 
being  included  in  the  section,  although  the  lines  of  division  extend  from 
one  curvature  to  the  other  and  involve  the  entire  circumference  of  the 
stomach.  By  gastric  resection  we  understand  removal  of  a  portion  of 
the  stomach  not  including  the  entire  lumen  of  the  organ;  the  term 
plastic  resection  we  think  therefore  properly  describes  the  operation 
called  gastroplasty  by  Jedlicka;  since  in  this  operation,  after  resection 
of  a  portion  of  the  anterior  wall  of  the  stomach,  he  reconstructs  the 
organ  by  a  plastic  operation.  Excision  in  connection  with  gastric 
operations  we  would  limit  to  the  removal  of  more  or  less  circum- 
scribed lesions  or  pedunculated  tumors  attached  to  or  springing  from 
the  stomach. 

As  many  of  these  operations  are  always  atypical  it  is  not  possible 
to  describe  them  in  detail.  It  being  well  appreciated  that  every 
surgeon  of  experience  developes  a  technique  more  or  less  peculiar 
to  himself,  and  that  all  that  can  be  asked  in  a  work  of  this  kind  is  an 
adequate  description  of  certain  typical  operations,  we  have  selected 
the  following  for  discussion:  I.  Pylorectomy,  by  Billroth's  first 
method.  II.  Partial  Gastrectomy,  including  Kocher's  method, 
and  Billroth's  second  method.  III.  Total  Gastrectomy.  IV.  Cyl- 
indrical Gastrectomy.     V.  Gastric  Resection. 

The  indications  for  the  employment  of  gastrectomy  have  been 
discussed  in  previous  chapters  (pp.  116,  298). 

Pylorectomy  by  Billroth's  First  Method.  This  operation 
was  first  performed  by  Pean  in  1879,  then  by  Rydygier  in  1880,  and 
first  successfully  by  Billroth  in  1881. 

Open  the  abdomen  by  an  incision  four  or  five  inches  (10  to  12  cm.) 
long,  close  to  the  median  line,  through  the  right  rectus  muscle.  Place 
sufficient  gauze  packs  in  the  lower  part  of  the  wound  to  keep  the  small 
intestines  and  transverse  colon  from  protruding.  Identify  the  stomach, 
and  doubly  ligate  the  coronary  artery  on  the  lesser  curvature  at  the 
site  selected  for  the  gastric  section,  and  cut  the  artery  between  the 
ligatures.  Doubly  ligate  the  gastro-epiploic  artery  on  the  greater 
curvature  at  the  other-. extremity  of  the  proposed  section,  and  divide 
it  between  the  ligatures.    Ligate  in  sections,  by  means  of  an  aneurism 


392  Technique  of  Operations. 

needle,  the  gastro-hepalic  and  the  gastro-cohc  omenta,  from  the  hne  of 
the  proposed  section  in  the  stomach  to  the  duodenum.  At  the  greater 
curvature  this  row  of  hgatures  should  pass  between  the  gastro- 
epiploic artery  and  the  transverse  colon,  great  care  being  exercised 
not  to  include  the  middle  colic  artery  in  any  of  the  ligatures.  The 
lesser  omentum  should  be  ligated  fairly  close  to  the  liver.  Thus  all 
enlarged  glands  will  be  removed  in  one  piece  with  the  stomach. 

Pass  a  gastrectomy  clamp,  with  rubber  sheathed  blades,  from  the 
greater  to  the  lesser  curvature,  at  the  site  of  the  proposed  section  of 
the  stomach.  Bring  its  points  out  far  enough  beyond  the  lesser 
curvature  to  grasp  firmly  between  the  blades  the  whole  of  the  pro- 
posed section  of  the  stomach.  Parallel  to  this  first  clamp  pass  a 
second  on  the  pyloric  side  of  the  gastric  section,  about  one  inch  distant 
from  the  first  clamp.  The  latter  clamp  need  not  have  its  blades 
covered  with  rubber.  Pass  a  hot  moist  sterile  gauze  pack  across  the 
lesser  peritoneal  cavity  from  one  curvature  of  the  stomach  to  the 
other,  immediately  beneath  the  two  clamps  already  placed.  Then 
divide  the  stomach  with  the  scalpel  or  the  actual  cautery  from  one 
curvature  to  the  other,  between  the  two  clamps,  but  close  to  the 
clamp  on  the  pyloric  side  of  the  section,  so  as  to  leave  enough  tissue 
protruding  from  the  rubber  covered  clamp  to  make  the  application  of 
sutures  easy.  Turn  the  pyloric  portion  of  the  stomach  thus  set  free 
over  to  the  patient's  right,  and  place  sufficient  gauze  behind  the  stom- 
ach and  pylorus  to  protect  thoroughly  the  lesser  peritoneal  cavity. 
Having  thus  mobiHzed  the  pyloric  portion  of  the  stomach,  it  will  be 
easy  to  detect  the  j)yloric  artery  on  tlie  lesser  curvature,  and  the  be- 
ginning of  the  right  gastro-epiploic  artery  on  the  greater,  just  below 
the  pylorus.  It  is  not  necessary  to  ligate  the  gastro-duodcnal  artery 
above  the  pylorus;  to  do  so  might  impair  the  blood  supply  to  the 
descending  duodenum  and  the  head  of  tlic  ])ancrcas.  When  the 
pyloric  and  right  gastro-epiploic  arteries  have  been  Ugatcd,  a  rubber 
covered  clamj)  is  to  be  applied  to  the  first  part  of  the  ckiodenum,  and 
the  ])}ioric  part  of  the  jjroposcd  (hiodenal  section  is  to  be  guarded  by 
another  clamp.  Close  to  tliis  latter  the  duodenum  is  next  divided  by 
scalpel  or  actual  cautery,  and  the  diseased  part  of  the  stomach  in- 
cluding the  pylorus  is  removed. 


Partial  Gastrectomy.  393 

The  gastric  segment  will  now  present  a  much  larger  area  than  the 
duodenal.  Hence  the  surgeon  should  begin  his  through-and-through 
sutures  at  the  lesser  curvature  of  the  gastric  segment,  and  close  this 
portion  of  the  stomach  from  above  downward  until  the  unsutured 
portion  presents  the  same  cahbre  as  does  the  duodenum.  The  latter 
is  then  drawn  across  to  the  gastric  segment  and  united  to  its  un- 
sutured portion  first  by  a  posterior  sero-serous  continuous  suture 
of  linen;  then  the  through-and-through  (iodized  gut)  suture  is  re- 
sumed, and  the  duodenum  united  to  the  stomach  throughout  the  cir- 
cumference of  the  bowel,  great  care  being  exercised  to  secure  accurate 
approximation  at  the  point  where  the  suture  line  of  the  gastric  section 
meets  the  gastro-duodenal  anastomosis.  This  point  of  junction  is 
known  as  the  "deadly  angle"  from  the  frequency  with  which  leakage 
has  occurred  there.  When  the  duodenum  and  stomach  are  thus 
united  securely  by  a  through-and-through  suture,  the  gastric  and 
duodenal  clamps  are  removed,  and  any  bleeding  points  reinforced  by 
specially  inserted  sutures.  Finally  the  entire  line  of  sutures,  both 
that  of  the  gastric  segment  and  that  of  the  anastomosis,  should  be 
inverted  by  a  continuous  sero-serous  suture.  The  gauze  packs  may 
now  be  removed;  the  remains  of  the  gastro-hepatic  and  gastrocolic 
omenta  are  stitched  to  the  upper  and  lower  portions  of  the  anasto- 
mosis, and  the  abdominal  wound  is  closed. 

Partial  Gastrectomy. — (i)  Kocher's  Method.  In  this  opera- 
tion the  distal  segment  of  the  divided  duodenum  is  implanted  (termino- 
lateral  anastomosis)  into  the  posterior  wall  of  the  stomach,  a  little  to 
the  left  of  the  gastric  section  which  is  entirely  closed.  Kocher  uses 
crushing  forceps  in  this  operation,  instead  of  the  rubber  covered 
clamps  employed  by  most  surgeons;  he  makes  the  section  of  the  stomach 
close  to  the  crushing  forceps,  and  as  a  consequence  it  is  necessary  for 
the  through-and-through  sutures  to  be  apphed  on  the  cardiac  side  of 
the  crushing  forceps.  Then  when  these  forceps  are  removed,  the 
projecting  tissue  is  trimmed  close  to  the  line  of  the  through-and- 
through  sutures,  and  the  latter  are  inverted  by  a  running  sero-serous 
suture.  The  following  description  of  the  operation  is  taken  from  the 
Enghsh  translation  by  Stiles  of  Kocher's  Operative  Surgery  (London, 
1903.  P-  215)- 


394  Technique  of  Operations. 

"After  ascertaining  exactly  the  hmits  of  the  tumour,  and  the 
mobihty  and  the  possibiHty  of  separating  glands,  the  lesser  omentum 
and  the  gastrocolic  ligament  are  perforated  at  the  margin  of  the  new 
growth  towards  the  fundus  of  the  stomach,  and  two  large  pressure- 
forceps  are  apphed  quite  close  to  each  other,  and  closed  as  firmly  as 
possible.  After  gauze  pads  have  been  placed  beneath  the  forceps 
(the  aseptic  protecting  pads  have  previously  been  placed  round  the 
parts  outside  the  abdomen)  the  stomach  is  cut  across  betAveen  the  two 
clamps,  close  up  to  the  one  to  the  right.  According  to  Hartmann's 
rule,  and  on  the  grounds  of  Cuneo's  observations,  the  clamps  must  be 
apphed  to  the  lesser  curvature  as  high  up  and  as  much  to  the  left  as 
possible;  and  in  order  that  the  glands  that  accompany  the  coronary 
vessels  may  at  the  same  time  be  removed,  it  appears  to  us  advisable  to 
double  ligature  and  cut  across  the  coronary  artery  above  the  point 
where  the  section  is  to  be  made.  By  dividing  bloodlessly  the  small 
omentum  above  the  glands  the  divided  stomach  is  rendered  so  movable 
that  it  can  be  turned  over  to  the  right  side, 

"Hartmann  places  value  on  the  last  procedure  because  the  fatty 
tissue  and  glands  can  then  be  followed  up  along  the  lesser  curvature 
and  can  be  included  in  the  removal  as  far  as  the  origin  of  the  pyloric 
and  the  gastroduodenal  branches  of  the  hepatic  artery.  The  latter 
vessel  is  carefully  avoided,  while  the  two  first  named  are  ligatured. 
After  throwing  the  stomach  over  towards  the  right  margin  of  the 
wound,  one  sees  quite  well  the  gastroduodenal  artery  running  down- 
wards in  the  groove  between  the  duodenum  and  pancreas.  In  this 
way  no  bleeding  should  occur  in  detaching  the  chain  of  glands  which 
accompany  this  artery  along  the  above-mentioned  groove.  We  can 
manage  quite  well  without  ligaturing  the  artery.  Throwing  the 
stomach  over  to  the  right  edge  of  the  wound  has  the  advantage  that 
by  drawing  upon  it  the  (Uiodenum  is  rendered  quite  accessible  from 
behind,  so  that  the  limits  of  the  new  growth  can  be  ascertained  with 
certainty,  and  one  can  determine  if  the  duodenum  be  long  enough 
and  movable  enough  to  enable  one  to  perform  gastroduodenostomy. 
When  this  is  the  case,  two  small  pressure-forceps  are  now  applied  to 
the  duodenum,  which  is  cut  across  between  them  with  the  knife  close 
up  to  the  pair  farther  removed  from  the  stomach,  a  small  pad  of 


Partial  Gastrectomy.  ^g^ 

gauze  having  previously  been  placed  under  the  part.  The  cut  edges 
are  then  carefully  and  thoroughly  cleansed. 

"The  opening  can  now  be  made  into  the  stomach  before  closing  it 
with  sutures,  because  the  forceps  in  position  afford  a  very  good  sup- 
port. A  pair  of  clamp-forceps  is  applied  to  the  duodenum  and  the 
accompanying  vessels,  and  the  crushing-forceps  are  removed.  The 
fingers  of  the  assistant  can  now  grasp  the  stomach  so  that  the  anterior 
wall  is  pressed  against  the  posterior  wall  at  the  place  where  the  in- 
cision has  been  made;  or  a  pair  of  clamp-forceps  may  be  applied  to 
the  stomach  after  it  has  been  closed  by  suturing  and  before  the  in- 
cision is  made  for  anastomosis  with  the  duodenum. 

"A  continuous  mattress  suture,  after  the  manner  of  a  half  Gely's 
suture,  is  carried  close  behind  the  crushing-forceps  (which  has  not 
been  removed  from  the  stomach) ;  only  the  commencement  is  knotted, 
and  by  pulling  on  the  two  ends  reliable  closure  is  effected.  If  the 
crushing-forceps  are  not  strong  enough  to  compress  the  tissues  so  that 
they  are  like  thin  dry  paper,  it  is  desirable  that  every  projecting  portion 
of  mucous  membrane  and  muscular  pulp  should  be  clipped  away 
with  scissors,  but  this  is  unnecessary  if  sufficiently  powerful  com- 
pression (crushing)  forceps  are  employed.  With  the  ends  of  the 
suture  held  taut,  a  continuous  glover's  suture  is  rapidly  applied  over  it 
so  as  to  fix  each  loop,  and  the  closure  is  completed  by  inverting  both 
by  a  continuous  serous  suture. 

"The  stomach  and  duodenum  are  now  clamped  at  some  distance 
from  the  place  where  they  have  been  opened,  or  are  to  be  opened,  and 
the  crushing  forceps  are  removed  from  the  duodenum.  Escape  of 
the  contents  being  carefully  prevented,  an  incision  is  made  into  the 
posterior  wall  of  the  stomach  near  the  greater  curvature  at  a  distance  of 
3  cm.  (about  one  inch  and  a  quarter)  from,  and  parallel  to,  the  sutures 
which  close  it,  at  first  merely  through  the  serosa,  for  a  length  equal  to 
the  breadth  of  the  duodenum.  The  posterior  segment  of  the  circular 
suture  is  now  apphed.  The  wall  of  the  stomach  is  then  completely 
cut  through  and  a  continuous  suture,  passing  through  all  the  coats,  is 
applied  so  as  to  unite  the  posterior  edges  of  the  opening  in  the  stomach 
and  duodenum.  A  third  continuous  suture  is  applied  so  as  to  unite 
the  two  mucous  edges.     The  anterior  edges  are  now  united  by  a  con- 


39^  Technique  of  Operations. 

tinuous  suture  which  passes  through  all  the  coats,  and  is  knotted  at 
each  end  to  the  posterior  suture.  The  clamp-forceps,  if  such  have 
been  employed,  are  removed,  and  lastly,  the  anterior  serous  suture  is 
applied  and  knotted  at  each  end  with  the  posterior  serous  suture." 

Remarks. — The  technique  employed  by  Kocher,  as  is  seen  from 
the  above  description,  closely  follows  that  originally  worked  out  by 
Hartmann,  in  that  the  stomach  is  divided  before  the  duodenum,  is 
then  turned  to  the  patient's  right,  and  the  duodenal  section  made  after 
clearing  the  glands  away  from  along  the  gastro-duodenal  artery.  The 
particular  part  of  the  operation  by  virtue  of  which  Kocher's  name  has 
been  attached  to  it,  consists  in  the  implantation  of  the  duodenum  into 
the  posterior  wall  of  the  stomach.  If  the  removal  of  the  stomach  has 
been  at  all  extensive,  it  is  very  likely  that  it  will  be  impossible  to  bring 
the  duodenum  and  stomach  into  apposition,  even  after  mobilizing 
the  duodenum.  In  such  circumstances  gastro-jejunostomy  should  be 
done. 

(2)  Billroth's  Second  Method. — This  method,  in  which  the 
operation  is  terminated  by  a  gastro-jejunostomy,  is  that  which  we  pre- 
fer to  employ  in  all  cases.  Usually  the  anastomosis  should  be  made 
in  the  posterior  wall  of  the  stomach;  but  if  the  patient's  condition  is 
bad,  or  if  the  remaining  portion  of  the  stomach  is  very  small,  anterior 
gastro-jejunostomy,  as  done  by  Billroth  himself,  may  be  adopted. 
The  use  of  a  Mur])hy  button  may  hasten  the  procedure  in  desperate 
cases. 

The  techni({ue  habitually  employed  at  the  German  Hospital  is 
the  following: 

After  exposing  the  stomach,  the  coronar}-  artery  is  identified, 
doubly  ligated  and  divided,  close  to  the  cardiac  orihce  of  the  stomach. 
The  finger  is  passed  through  the  gastro-hepatic  omentum  into  the 
lesser  peritoneal  ca\'ity,  and  the  gastro-hepatic  omentum  is  ligated  in 
.sections,  fairly  close  to  the  transverse  fissure  of  the  liver.  By  cutting 
through  the  gastro-hepatic  omentum,  the  surgeon  reaches  the  pyloric 
artery,  which  is  doubly  ligated  and  cut.  The  linger  is  then  passed 
down  behind  the  pylorus,  and  the  right  gastro-ei)ipl()ic  arler)'  is  identi- 
fied below  the  jn-Iorus;  this  artery  is  ligated,  but  is  not  cut.  H;emo- 
static  forceps  are  then  a])plied  to  the  gastrocolic  omentum,  and  as 


Partial  Gastrectomy. 


397 


they  are  applied  this  structure  is  divided  between  them,  beginning  at 
the  pylorus  and  passing  along  the  upper  border  of  the  transverse  colon 
until  the  point  is  reached  at  which  it  is  proposed  to  divide  the  stomach. 
This  point  should  be  two  inches  to  the  left  of  the  visible  malignant 


/ 


r 


Fig.  68. — Partial  Gastrectomy:    Division  of  Gastro-colic  Omentum. 


growth.     When  this  point  has  been  reached,  the  left  gastro-epiploic 
artery  is  ligated  just  to  the  left  of  the  proposed  gastric  incision.     In 
placing  the  haemostats  on  the  gastro-colic  omentum,  great  care  is  to 
be  taken  to  avoid  the  middle  colic  artery  and  its  branches  (Fig.  68). 
The  portion  of  stomach  to  be  removed  is  now  completely  freed 


398 


Technique  of  Operations. 


along  its  curvatures,  and  remains  attached  only  to  the  duodenum  and 
the  body  of  the  stomach.  The  lesser  peritoneal  cavity  can  now  be 
protected  thoroughly  by  sterile  gauze  compresses.  A  clamp  -with 
rubber-covered  blades  is  now  applied  to  the  duodenum  about  one 
inch  beyond  the  portion  visibly  diseased,  and  an  ordinary  clamp  is 
applied  just  to  the  pyloric  side  of  the  first  clamp.     The  duodenum  is 


Fig.  69. — Partial  Gastrectomy:    The  Duodenum  has  been  Divided,  and  the 
Clamps  are  in  Place  for  the  Gastric  Section. 


then  divided  between  the  two,  the  section  cutting  also  the  right  gastro- 
epiploic arter}'  (already  ligated)  below  the  pylorus.  The  entire  por- 
tion of  the  stomach  to  be  excised  can  now  be  turned  to  the  patient's 
left.  The  duodenal  stump  is  closed  first  b\-  a  through-and-through 
iodized  catgut  suture;  before  the  occluding  clamp  has  been  removed 
a  purse-string  suture  of  linen  is  apjjlied  on  the  distal  (duodenal)  side 


Partial  Gastrectomy. 


399 


of  the  clamp;  the  clamp  is  then  removed,  and  by  catching  the  duodenal 
wall  in  two  places  with  dissecting  forceps,  the  sutured  end  of  the 
duodenum  is  inverted  and  the  purse-string  suture  is  drawn  tight 
and  tied.  Sometimes  a  few  additional  Lembert  sutures  of  linen  are 
inserted  to  re-inforce  those  previously  placed.  As  the  duodenum  is 
divided  where  part  of  its  wall  is  retroperitoneal,  it  is  very  important  to 


Fig. 70. 


-Partial  Gastrectomy:  Through-and-through  Sutures  being  Applied 
TO  the  Gastric  Section. 


suture  it  accurately;  but  usually  the  through-and-through  suture  and 
the  purse- string  suture  are  all  that  is  necessary.  The  gastro-colic 
•omentum  is  then  ligated,  and  the  haemostatic  forceps  removed. 

Rubber- covered  gastrectomy  clamps  are  then  applied  across  the 
stomach  from  the  greater  to  the  lesser  curvature,  at  least  two  inches 
to  the  left  of  the  visible  malignant  growth  (Fig.  69).     Clamps  with 


400 


Technique  of  Operations. 


a  screw  lock  at  the  end  of  the  blades,  as  in  Kocher's  clamps,  arc 
safest.  The  entire  lesser  curvature  is  always  removed,  but  the  line  of 
the  section  passing  from  that  point  to  the  greater  curvature  varies  with 
the  extent  of  the  tumor.     About  three-fourths  of  an  inch  to  the  right  of 


Fig.  71. — Partial  Gastrkctomy:    Sero-serous  Sutures  being  Applied  to  the 

Stomach. 


this  occluding  clam]),  an  orfHnary  forccj)S  is  appliud,  and  tlic  stomacli 
is  divided  bclwccn  the  two  with  the  I'atnK  lin  (  autery.  The  excised  por- 
tion being  remoxed,  a  through  and-through  suture  of  ioch'zcfl  catgut  is 
inserted  through  the  margins  of  the  gastric  walls  which  protrude  from 


Partial  Gastrectomy.  401 

between  the  blades  of  the  rubber-covered  clamp  (Fig.  70).  It  is  well 
to  grasp  these  margins  at  one  or  more  points  with  forceps  to  prevent 
their  retracting.  When  the  through-and-through  sutures  have  been 
completed,  the  clamp  is  removed,  and  a  continuous  sero-serous  suture 
is  applied,  burying  the  first  row,  and  carefully  re-inforcing  any  points 
that  tend  to  bleed  (Fig.  71). 

The  transverse  colon  is  then  drawn  out  of  the  wound,  and  the 
posterior  gastric  wall  is  exposed  by  opening  the  transverse  mesocolon. 
A  posterior  gastro-jejunostomy  is  then  done  by  the  usual  technique, 
as  described  at  page  381,  and  as  indicated  diagrammatically  in  Fig.  71. 

Finally,  after  suturing  the  mesocolon  to  the  posterior  gastric 
wall,  and  replacing  the  newly  formed  anastomosis  within  the  abdomen, 
the  great  omentum  is  dravm  up  to  cover  the  space  left  by  the  removal 
of  the  stomach,  and  the  abdominal  wound  is  closed. 

Subtotal  gastrectomy  differs  from  partial  gastrectomy  only  in 
the  extent  of  the  stomach  removed.  A  precisely  similar  technique 
may  be  employed.  In  some  cases,  however,  there  will  be  so  small  a 
portion  of  the  cardia  left  that  only  an  anterior  gastro-jejunostomy  can 
be  done. 

Remarks. — It  is  seen  that  the  technique  of  partial  gastrectomy  as 
above  given  is  practically  identical  with  that  described  by  Mayo 
in  1904.  Although  the  technique  of  Hartmann,  in  which  the  gastric 
section  is  made  first,  and  the  tumor  then  turned  to  the  patient's  right, 
before  dividing  the  duodenum,  presents  the  undoubted  advantage  of 
approaching  the  dangerous  retro-pyloric  region  in  an  open  and  strictly 
anatomical  way,  yet  it  has  the  disadvantage,  as  pointed  out  by  Mayo, 
of  being  less  easy  of  accomplishment  than  the  method  in  which  the 
duodenum  is  divided  first;  because  the  line  of  proposed  section  of  the 
stomach  is  frequently  difficult  of  access  until  the  stomach  is  mobilized 
by  section  of  the  duodenum.  We  would  point  out,  moreover,  that 
Mayo's  operation  has  the  distinct  advantage  that  the  occluding  clamps 
are  not  applied  to  the  stomach  until  the  last  possible  moment,  and 
that  they  are  kept  in  place  for  the  very  shortest  possible  time — in  fact, 
only  until  it  is  possible  to  insert  the  through-and-through  sutures. 
There  is  thus  scarcely  any  risk  of  interference  with  the  vascular 
supply  of  the  sutured  edges. 
26 


402 


Technique  of  Operations. 


Total  Gastrectomy. — In  rare  cases  after  the  abdomen  has  been 
opened  it  may  be  found  that  the  disease  has  invaded  so  great  an  area 
of  the  stomach  as  to  render  its  entire  removal  desirable,  while  at  the 


Fig.  72. — Portion  of  Carcinomatous  Stomach  Removed  by  Partial  Gastrec- 
tomy.    Half  Natur.\l  Size.     {From  a  patient  hi  the  German  Hospital.) 

same  time  no  secondary  growths  or  adhesions  exist  which  will  render 
such  an  operation  impracticable. 


V '  ■* 


Fig.  73. — Specimen  Shown  in  Fig.  72  Split  open  through  Pylorus.     Half 

Natural  Size. 

The  operation  should  jjroceed  along  the  same  lines  as  partial 
gastrectomy,  until  the  duodenum  has  been  divided.  It  is  then  to  be 
detcrmincfl  whether  tlic  duocknum  can  Ijc  made  to  reach  the  oesoph- 


Cylindrical  Gastrectomy.  403 

agus  without  undue  tension.  Mobilization  of  the  duodenum,  as  in 
operations  on  the  retro-duodenal  portion  of  the  common  bile  duct,  may 
render  this  possible.  If  the  duodenum  can  be  made  to  reach  the 
oesophagus,  it  should  be  attached  to  the  latter  by  a  primary  posterior 
row  of  sutures  before  the  cardiac  orifice  of  the  stomach  is  divided. 
Then  the  cardia  is  clamped,  divided  above  the  clamp,  and  the  union 
of  the  duodenum  to  the  oesophagus  completed,  an  end-to-end  anastomo- 
sis being  performed  in  the  usual  way.  If  the  duodenum  cannot  be 
made  to  reach  the  oesophagus,  a  coil  of  the  upper  jejunum,  provided 
with  a  long  mesentery,  should  be  selected;  the  jejunum  should  be 
divided  completely  across,  its  distal  end  being  united  to  the  oesophagus 
by  circular  (end-to-end)  anastomosis,  and  the  proximal  end  being  im- 
planted into  the  distal  segment  at  a  convenient  distance  below  the 
oesophago-jejunal  anastomosis.  The  jejunum  should  be  united  to  the 
oesophagus  by  the  trans-mesocolic  route  if  possible.  The  Murphy 
button  may  be  employed  if  accurate  suturing  is  impossible. 

Should  the  surgeon  be  so  heedless  as  to  remove  the  entire  stomach 
before  determining  whether  any  portion  of  the  intestinal  tract  can  be 
anastomosed  to  the  oesophagus,  he  should  suture  the  divided  end  of 
the  duodenum  into  the  abdominal  wound ;  should  this  be  impossible, 
jejunostomy  may  be  a  last  resort. 

It  might  be  possible  to  connect  the  oesophagus  and  duodenum 
by  an  excluded  loop  of  the  jejunum,  transplanted  through  the  trans- 
verse mesocolon,  somewhat  after  the  manner  of  Herzen's  operation 
of  gastrostomy. 

Vassalo  reports  a  case  of  total  gastrectomy  in  which  the  entire  time 
consumed  in  the  operation  was  only  thirty-eight  minutes. 


CYLINDRICAL  GASTRECTOMY. 

Cylindrical  Gastrectomy. — This  operation  is  suitable  only  for 
benign  lesions  occupying  the  middle  zone  of  the  stomach.  If  there 
exist  an  ulcerated  area  which  does  not  obstruct  either  orifice  of  the 
stomach,  as  is  the  case  with  some  ulcers  along  the  lesser  curvature; 
and  if  some  form  of  radical  operation  is  to  be  preferred  to  gastro- 
jejunostomy, then  a  cylindrical  gastrectomy  frequently  will  be  simpler 


404  Technique  of  Operations. 

and  easier  of  accomplishment  than  resection  of  a  V-shaped  area  from 
the  lesser  curvature.  In  some  cases  of  hour-glass  stomach  cylindrical 
gastrectomy  may  be  of  benefit. 

We  entirely  agree  with  Leriche,  however,  in  his  dictum  that  cylin- 
drical gastrectomy  is  absolutely  contra-indicated  if  there  are  enlarged 
glands  in  the  gastro-hepatic  omentum;  but  we  would  go  further,  and 
prohibit  its  employment  in  every  case  of  malignant  disease,  because 
under  such  circumstances  the  entire  lesser  curvature  should  be  re- 
moved. Leriche,  who  is  a  supporter  of  excision  of  benign  lesions  in 
general,  makes  the  bold  but  possibly  significant  statement  that  if  this 
operation  were  more  often  done  for  non-stenosing  cancer,  more  cases 
of  progressive  pernicious  anaemia  would  be  cured. 

The  operation  may  be  performed  thus :  After  exposing  the  stomach 
and  ligating  the  main  arteries  at  the  extremities  of  the  proposed 
sections,  two  pairs  of  rubber-covered  clamps  are  applied,  including 
between  them  the  portion  of  stomach  to  be  removed,  which  should  be 
emptied  as  completely  as  possible  before  tightening  the  clamps.  The 
gastro-colic  and  gastro-hepatic  omenta  are  next  ligated,  and  divided. 
The  diseased  portion  of  the  stomach  is  then  cut  away,  and  the  divided 
surfaces  of  the  stomach  united  by  circular  gastrorrhaphy  (end-to-end 
anastomosis).  Leriche  calls  attention  to  the  advantages  of  commenc- 
ing and  terminating  the  continuous  sutures,  not  at  one  of  the  curva- 
tures of  the  stomach,  where  the  peritoneal  coat  is  defective,  but  at 
some  convenient  point  on  the  anterior  gastric  wall.  If  the  two 
portions  of  the  stomach  do  not  meet  with  the  utmost  facility,  that 
is  to  say,  if  there  be  the  very  least  tension  on  the  sutures  anywhere,  it 
will  be  possible  to  overcome  this  by  mobilization  of  tlie  duodenum. 
In  some  cases  it  may  seem  Ijctter  to  terminate  the  operation  as  in 
exclusion  oj  Ike  pylorus,  ])y  closing  bolli  gastric  segments  and  doing  a 
separate  gastro-jejunostomy. 

GASTRIC  RESECTION. 

Gastric  Resection. —  Removal  of  a  iced i;;c- shaped  area  from  the 
lesser  curx'ature  of  the  slf)mach  may  be  accom])lishc(l  b)-  appl}-ing 
rubber-covered  {lam])s  outside  of  the  ])roposfd  linrs  of  scclion,  after 


Gastric  Resection.  405 

tying  off  the  gastro-hepatic  omentum.  Tfie  wounds  left  may  then  be 
sutured  the  one  to  the  other,  thus  approximating  the  cardiac  and 
pyloric  orifices.  This  mode  of  reunion  may  prove  difficult  or  even 
impossible ;  under  which  circumstances  a  complicated  form  of  plastic 
operation  may  have  to  be  undertaken.  This  operation,  therefore, 
is  not  one  to  be  lightly  undertaken;  indeed  we  cannot  see  that  it 
presents  any  advantages  over  cylindrical  gastrectomy.  Jedhcka  has 
adopted  a  form  of  plastic  resection  of  the  stomach  which  he  calls  gas- 
troplasty. By  this  operation,  after  removing  the  diseased  portion  of 
the  lesser  curvature  and  of  the  anterior  or  posterior  walls  of  the 
stomach,  he  reconstructs  the  natural  contour  of  the  stomach  by  the 
method  of  sliding  flaps.  In  one  case  the  operation  took  two  hours  and 
a  quarter. 

Resection  of  the  cardia,  founded  on  the  advances  in  thoracic 
surgery  inaugurated  by  Sauerbruch  and  by  Brauer,  has  been  accomp- 
lished in  one  case  of  carcinoma  by  Wendel  with  the  use  of  Brauer's 
positive  pressure  air  chamber  around  the  patient's  head.  He 
operated  on  Sept.  6,  1906,  making  an  incision  six  inches  and  a  half 
(16  cm.)  long  in  the  sixth  left  costal  interspace,  cutting  through  the 
seventh  costal  cartilage.  Some  adhesions  between  the  lung  and 
pleura  were  separated,  and  the  lung  was  excluded  from  the  field  of 
operation  by  the  use  of  gauze  packs.  The  vagi  were  then  freed 
without  difficulty,  the  lower  end  of  the  oesophagus  isolated,  and  gauze 
was  passed  behind  it.  The  oesophagus  was  then  freed  from  the 
diaphragm.  This  work  was  absolutely  in  the  dark,  and  accomplished 
only  by  the  sense  of  touch;  it  was  very  difficult;  there  was  free  arterial 
bleeding,  and  the  bleeding  points  were  very  difficult  to  ligate.  The 
time  consumed  was  now  an  hour  and  a  half.  It  was  found  impos- 
sible to  do  an  anastomosis  between  the  oesophagus  and  the  stomach 
to  one  side  of  the  tumor,  so  resection  was  undertaken.  The  tumor 
could  be  drawn  out  through  the  diaphragm  and  across  the  pleural 
cavity,  even  to  the  thoracic  wound.  It  was  surrounded  by  gauze 
packs.  The  vagi  were  found  entering  the  tumor  and  could  not  be 
dissected  free  lower  down.  They  were  therefore  cut  off  i  cm.  (less 
than  half  an  inch)  from  their  point  of  entrance  into  the  tumor.  The 
oesophagus  was  next  divided,  and  its  end  closed  by  sutures.     Before 


4o6  Technique  of  Operations. 

this  was  done,  however,  the  male  half  of  a  Murphy  button  was  in- 
serted into  the  oesophagus,  and  later  was  liberated  by  making  a  slit  in 
the  side  of  the  latter.  The  gastric  incision  included  practically  all  of 
the  lesser  curvature,  and  a  good  deal  of  the  fundus  of  the  stomach. 
The  female  half  of  the  button  was  passed  into  the  cavity  of  the  stomach 
through  the  gastric  wound,  which  was  then  completely  closed,  the  shank 
of  the  button  being  made  to  protrude  at  another  point  of  the  gastric 
wall,  where  it  was  exposed  by  a  puncture,  and  the  two  halves  of  the 
button  approximated.  Finally  the  margins  of  the  diaphragmatic 
incision  were  sutured  to  the  stomach  below  the  anastomosis,  and  the 
intercostal  wound  was  closed,  with  a  strip  of  gauze  for  drainage.  The 
time  of  the  entire  operation  was  somewhat  over  two  hours.  Although 
the  patient  reacted  well,  death  occurred  suddenly  the  next  morning 
from  secondary  hemorrhage.  The  bleeding  was  found  to  come  not 
from  the  line  of  sutures,  but  probably  from  one  of  the  vessels  which 
had  been  so  difficult  to  ligate. 

A  similar  operation  had  been  done  previously,  and  with  success, 
several  times  on  dogs,  by  Sauerbruch  and  by  Sencert,  and  it  had  been 
attempted  in  two  cases  by  Sauerbruch  on  man,  but  the  patient  in 
whom  resection  was  attempted  died  on  the  table,  and  in  the  other  the 
tumor  was  found  to  be  inoperable,  and  an  oesophago-gastric  anas- 
tomosis was  done,  the  patient  dying  in  24  hours. 

Wiener,  in  a  patient  with  carcinoma  of  the  lesser  curvature  of  the 
stomach  invading  the  cardia,  employed  osteo-plastic  resection  of  the 
costal  arch,  under  gas  and  ether  anaesthesia,  and  thirty  days  later,  under 
spinal  anaesthesia,  excised  the  growth,  doing  ocsophago-gastrostomy. 
Death  occurred  in  eleven  days,  and  was  found  to  be  due  to  a  sub- 
phrenic abscess  occasioned  by  separation  of  the  oesophago-gastric 
anastomosis.  Wiener  suggests  doing  a  ccr\ical  ocsophagostomy 
of  the  lower  end  of  the  oesophagus,  and  a  gastrostomy,  instead  of 
attempting  to  unite  the  oesophagus  and  stomach. 


Jejunostomy. 


407 


JEJUNOSTOMY. 

Jejunostomy. — This  operation  was  first  employed  in  1878  by 
Surmay,  of  Ham,  in  the  case  of  a  patient  with  carcinoma;  death 
occurred  the  next  day,  from  peritonitis. 

Karewski  adopted  the  method  oj  Witzel  for  gastrostomy.  A.  coil 
of  the  jejunum  about  45  cm.  (18  in.)  from  its  origin  is  selected,  and 
the  catheter  is  sutured  in  place,  as  shown  in  Fig.  74,  with  its  eye 


"''^^-^i 


Fig.  74. — Jejunostomy  by  the  Method  of  Karewski. 


end  toward  the  anal  end  of  the  bowel.  Then  the  bowel  is  attached 
to  the  parietal  peritoneum  at  the  edges  of  the  abdominal  incision,  and 
the  latter  is  sutured  close  up  to  the  tube.  Feeding  should  be  begun 
at  once. 

In  Maydl's  operation  the  jejunum  is  completely  divided  about 
20  cm.  (8  inches)  below  its  origin,  the  proximal  segment  is  implanted 
(end-to-side  anastomosis)  into  the  distal  about  20  to  30  cm. (8  to  12  in.) 


4o8 


Technique  of  Operations. 


below  the  section,  and  the  distal  segment  is  sutured  end-on  into  the 
abdominal  wound  (Fig.  75). 

Duodenostomy,  in  which  the  fistula  is  made  (after  the  method  of 
Witzel  and  Karcwski)  in  the  duodenum  above  the  bile  papilla,  is  pre- 
ferred to  jejunostomy  by  Hartmann. 


Fig.  75. — Jejunostomy  in  Y.     Method  of  Mavdl. 


REFERENCES. 

Baudouin:     Annales    Internat.   de   Chir.    Gastro-Intest.,     1907,    i,     124. 

(Gastrostomy.) 
Bennett's  Gastr()|)lic;ilion:   See  Robson,  Lancet,  1900,  i,  831. 
Beyea:  See  Stengel  and  lieyea.  Trans.  Coll.  Phys.  Phila.,  1899,  xxi,  76. 
Billroth:   Wien.  med.  Woch.,  1881,  x.\xi,  i6t. 
Bircher:    Corr.-Bl.    f.   Schweizer    Aerzle,   1891,    xxi,  713.     (Gastroplica- 

tion.) 


References.  409 

Bircher:   Zentralbl.  f.  Chir.,  1907,  xxxiv,  1479.     (Gastrostomy.) 

Braun:  Verhandl.  d.  Deutsch.  Gesellsch.  f.  Chir.,  XXI  Congr.,  1892, 
ii,  515;  Arch.  f.  klin.  Chir.,  1893,  xlv,  361. 

Doyen:  Verhandl.  d.  Deutsch.  Gesellsch.  f.  Chir.,  XXVII  Congr.,  1898, 
ii,  202. 

Durante:  Cited  by  Ricard  and  Chevrier,  loc.  infra  cit. 

Duret:  Revue  de  Chir.,  1896,  xvi,  421. 

Finney:  Trans.  Amer.  Surg.  Assoc,  1902,  xx,  165. 

Fowler:  Trans.  Amer.  Surg.  Assoc,  1902,  xx,  347. 

Frank:  Wien.  klin.  Woch.,  1893,  vi,  231. 

Gaston:  Atlanta  Med.  and  Surg.  Jour.,  1884-5,  i,  336,  385;  Ibid., 
1885-6,  ii,  395,  533. 

Gluck:   Cited  by  Bircher,  Zentralbl.  f.  Chir.,  1907,  xxxiv,  1479. 

Gould:  "Technic  of  Operations  upon  the  Intestines  and  Stomach." 
Phila.  and  London,  1906,  p.  172.  (McGraw's  method  of 
Gastro-jejunostomy.) 

Gould:  Ibid.,  p.  206.     (Gastrostomy.) 

V.  Hacker:  Arch.  f.  klin.  Chir.,  1885,  xxxii,  621. 

Hahn:   Centralbl.  f.  Chir.,  1890,  xvii,  193. 

Hartmann:  Travaux  de  Chir.  Anatomo-cHnique,  Paris,  1903,  i.  (Gas- 
trectomy.) 

Hartmann:  Ibid.,  loc.  cit.,  p.  351.     (Duodenostomy.) 

Hartmann:  Bull,  et  Mem.  de  la  Soc  de  Chir.  de  Paris,  1904,  xxx,  198. 
(Duodenostomy. ) 

Herzen:   Zentralbl.  f.  Chir.,  1908,  xxxv,  219. 

Jaboulay:  Arch.  Prov.  de  Chir.,  1892,  i,  i;  429. 

JedHcka:    Operat.  Behandl.  d.  chron.  Magengeschwiirs,  Prag  1904. 

Jonnesco:   Revue  de  Chir.,  1907,  xxxv,  601. 

Kader:   Centralbl.  f.  Chir.,  1896,  xxiii,  665. 

Kammerer:   Annals  of  Surg.,  1903,  xxxvii,  281. 

Karewski:  Berl.  klin.  Woch.,  1896,  xxxiii,  11 12. 

Kocher:   Centralbl.  f.  Chir.,  1891,  xviii,  Beil.,  117.     (Gastrectomy.) 

Kocher:   Operative  Surgery,  London,  1903,  p.  215.     (Gastrectomy.) 

Kocher:   Ibid.,  p.  431.     (Gastro-duodenostomy.) 

Krukenberg:  See  Schmid-Monnard,  Munch,  med.  Woch.,  1893,  ^^^  35^- 

Lambotte:   Cited  in  Jour,  de  Chir.,  1908,  i,  7. 

Lauenstein:  "Zur  Indie,  Anleg.  u.  Funct.  d.  Magen-diinndarmfistel," 
1891;  cited  by  Braun,  loc  supra  cit. 

Leriche:   Revue  de  Chir.,  1906,  xxxiv,  no.     (Gastro-duodenostomy.) 

Leriche:  Annales  Internat.  de  Chir.  Gastro-Intest.,  1907,  i,  100.  (Cylin- 
drical Gastrectomy.) 

Lucke:  Wien.  klin.  Woch.,  1899,  xii,  538. 

McGraw:  Jour.  Amer.  Med.  Assoc,   1891,  xvi,  685;   N.  Y.  Med.  Jour., 

1901, h  133- 
McLean:  Jour.  Mich.  State  Med.  Soc,  Detroit,  1903,  ii,  550. 
Maydl:  Mitth.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1898,  iii,  532. 
Mayo:   Annals  of  Surgery,  1904,  xxxix,  321.     (Gastrectomy.) 


410  Technique  of  Operations. 

Mayo:    Ibid.,  1906,  i,  537.  ■  (Direction  of  jejunal   loop   in    gastro-jejun- 

ostomy.) 
Mayo:  Ibid.,  1908,  i,  i.     (Mesocolic-jejunal  fold,  of  peritoneum.) 
Moynihan:  Annals  of  Surgery,  1908,  i,  481.      (Direction  of  jejunal  loop 

in  gastro-jejunostomy.) 
Murphy:  Brit.  Med.  Jour.,  Nov.  24,  1906. 
NicoU:   Glasgow  Med.  Jour.,  1906,  Ixv,  253. 
Pean:   Gaz.  d.  Hopitaux,  1879,  ^^h  473- 
Petersen:   Beitr.  z.  klin.  Chir.,  1901,  xxix,  597. 
Ricard  and  Chevrier:   Revue  de  Chir.,  1905,  xxxii,  74. 
Rockwitz:   Deutsch.  Zeit.  f.  Chir.,  1887,  xxv,  555. 
Roux:    Rev.   de   Gyn.    et   Chir.  Abd.,  1897,  i,  67.     (Gastro-jejunostomy 

in-Y.) 
Roux:    Semaine  Med.,  1907,  xxvii,  37.     (Gastrostomy.) 
Rydygier:   Deutsch.  Zeit.  f.  Chir.,  1880-1,  xiv,  252. 
Sauerbruch:     Beitr.     z.    klin.     Chir.,     1905,    xlvi,    485.     (Experimental 

resection  of  cardia  on  dogs.) 
Sauerbruch:   Mlinch.  med.  Woch.,  1906,  liii,  3.     (Resection  of  cardia.) 
Sedillot:   Comptes  Rendus  de  1' Academic  des  Sciences,  1849,  xxix,  565. 
Sencert:  Revue  de  Gyn.  et  de  Chir.  Abd.,  1905,  ix,  496.     (Gastrostomy.) 
Sencert:   Ibid.,  loc.  cit.,  p.  469.     (Experimental  resection  of  cardia.) 
Senn:  Jour.  Amer.  Med.  Assoc,  1896,  ii,  1142. 
Ssbanajew:   Centralbl.  f.  Chir.,  1893,  xx,  862. 
Stamm:  Medical  News,  Sept.  22,  1894. 
Stavely:  Johns  Hopkins  Hosp.  Bull.,  Sept.,  1908. 
Surmay:   Bull,  de  Therap.  Med.  et  Chir.,  Paris,  1878,  xxiv,  198. 
Tavel:  Corresp.-Bl.  f.  Schweizer  Aerzte,  1906,  xxxvi,  397. 
Ulmann:  Wien.  med.  Woch.,  1894,  xliv,  1662. 
Vassalo:   Annales  Internat.  de  Chir.  Gastro-Intest.,  1906,  i,  60. 
Wendel:   Arch.  f.  klin.  Chir.,  1907,  Ixxxiii,  635. 
Witzel:  Centralbl.  f.  Chir.,  1891,  xviii,  601. 

Wolfler:   Centralbl.  f.  Chir.,  1881,  viii,  705.     (Gastro-enterostomy.) 
Wolfler:   Beitr.  z.  klin.  Chir.,  1895,  xiii,  221.     (Gastro-gastrostomy.) 
WuUstein:   Deutsch.  med.  Woch.,  1904,  i,  734. 


CHAPTER  XV. 
COMPLICATIONS  AND  SEQUELS. 

The  operations  which  are  now  employed  in  the  treatment  of  gastric 
diseases  are  much  less  frequently  followed  by  untoward  symptoms 
than  was  the  case  in  the  earlier  periods  of  the  surgery  of  the  stomach. 
Yet  certain  complications  and  sequels  still  demand  attentive  study  by 
the  surgeon,  because  even  now  a  patient  is  occasionally  seen  who  has 
been  operated  on  by  an  antiquated  method,  and  who  presents  the 
symptoms  of  one  of  the  sequels  formerly  not  unusual.  Moreover, 
there  are  certain  complications  and  sequels  which  are  due  to  the 
original  disease,  and  not  to  the  operative  treatment :  these  will  always 
deserve  careful  consideration. 

The  main  subjects  to  be  considered  in  this  chapter  are : 

1.  The  Causes  of  Death  after  Operation,  including  Shock, 

Peritonitis,  and  Pneumonia. 

2.  The  Vicious  Circle  after  Gastro-jejunostomy. 

3.  Peptic  Ulcer  of  the  Jejunum  after  Gastro-jejunostomy. 

4.  Internal  Hernia. 

5.  Gastric  Fistulae. 

6.  Duodenal  Fistulas. 

7.  Subphrenic  Abscess. 

I.  The  Causes  of  Death  after  Operation. — The  chief  of  these 
are  Peritonitis,  Pneumonia,  Shock,  and  the  Vicious  Circle.  Unfor- 
tunately most  writers,  while  narrating  their  successes  in  glowing  terms, 
have  not  dwelt  particularly  on  the  details  of  their  fatal  cases,  giving 
only  general  expressions  of  opinion  as  to  the  most  frequent  cause  of 
death. 

Among  92  operations  for  benign  diseases  of  the  stomach,  done  by 
Dr.  Deaver  at  the  German  Hospital,*  the  records  of  which  were 

*  It  is  much  to  be  regretted  that  many  operations  done  by  Dr.  Deaver  in  other 
hospitals,  and  at  the  patients'  homes,  cannot  be  included,  owing  to  lack  of  details. 

411 


412  Complications  and  Sequels. 

analyzed  for  us  by  Dr.  Whiting,  there  were  8  deaths.  In  two  pa- 
tients (Nos.  I  and  8),  one  operated  on  in  1900,  the  other  in  1903, 
the  cause  of  death  is  not  noted  in  the  records.  Death  was  attributed 
to  exhaustion  in  one  patient  (No.  47),  referred  to  at  page  in,  who  was 
almost  exsanguinated  from  repeated  hemorrhages  before  operation,  but 
lived  for  forty-eight  hours  afterward.  Two  patients  (Nos.  7  and  27), 
one  in  1902,  the  other  in  1905,  died  of  peritonitis,  which  was  in  each 
instance  due  to  leakage  of  the  Murphy  button  employed  in  doing  an 
entero- anastomosis  for  vicious  circle  some  days  after  the  primary 
operation  (posterior  gastro-jejunostomy  with  a  long  afferent  loop). 
One  patient  (No.  20),  operated  on  in  1904,  died  from  the  effects  of 
the  vicious  circle  following  the  posterior  "long  loop"  operation,  relief 
not  being  obtained  from  a  secondary  operation  in  which  the  distended 
afferent  loop  was  resected  with  end-to-end  anastomosis.  One  patient 
(No.  82)  with  phthisis  died  of  oedema  of  the  lungs  developing  on  the 
eighth  day  after  the  operation;  and  one  patient  (No.  67),  with  sub- 
acute perforation  of  a  gastric  ulcer,  died  three  weeks  after  operation 
from  nephritis  and  myocardial  disease. 

It  is  true  that  in  some  of  these  patients  the  operation  itself  cannot 
be  held  directly  responsible  for  the  fatal  termination;  but  neverthe- 
less it  is  probable  that  six  of  the  patients  would  not  have  died  quite  so 
.soon  had  no  operation  been  undertaken.  The  patient  with  hemor- 
rhages, who  lived  two  days  after  operation,  and  the  patient  with  the 
perigastric  abscess  and  diseased  heart  and  kidneys  would  almost  cer- 
tainly have  died  as  soon  as  they  did,  if  not  indeed  sooner,  had  no 
operation  been  employed. 

Among  46  operations  by  Dr.  Deaver  at  the  German  Hospital  for 
carcinoma  of  the  stomach,  there  were  13  deaths. 

Among  31  gastro-jejunostomies — 

I  death  was  ckie  to  shock,  the  patient  dying  in  a  few  hours. 

3  deaths  were  due  to  exhaustion,  the  patients  dying  after 

intervals  of  12  days,  15  days,  and  7  days,  respectively. 
I  deatli  was  (hie  to  Jicarl  jai/urc,  on  the  7th  day. 
I  death  was  due  to  iira'mia,  on  the  3(1  day. 

4  deaths  were  due  to  pcrilonilis,  after  4  days,  6  days,  1 1  days, 

and  15  days,  respectively. 


Causes  of  Death.  413 

Among  14  partial  gastrectomies — 

1  death  was  due  to  shock,  the  patient  dying  in  i^  hours. 

2  deaths  were  due  to  peritoniiis,  after  13  days  and  3  days, 

respectively. 
Graf  has  recently  tabulated  the  causes  of  death  in  7  patients 
among  86  operated  on  by  Helferich.     These  may  be  of  interest  when 
compared  with  the  figures  just  given. 

3  deaths  from  hamatemesis  persisting  after  jejunostomy. 
2  deaths  from  shock. 

I  death  from  ancesthetic. 
I  death  from  pneumonia. 

There  were  five  other  patients  who  developed  pneumonia  or  bron- 
chitis after  the  operation,  but  these  all  recovered.  There  were  no 
deaths  attributable  to  peritonitis  or  to  the  vicious  circle. 

The  subject  of  the  Vicious  Circle  after  gastro- jejunostomy  deserves 
a  section  to  itself.  It  will  be  sufficient  here  to  refer  rather  briefly  to 
the  subjects  of  shock,  pneumonia,  and  peritonitis,  complicating  and 
following  operations  on  the  stomach. 

Shock  is  chiefly  due  to  undue  prolongation  of  the  operation  on  the 
surgeon's  part,  or  to  pre-existing  cachexia  on  that  of  the  patient.  It  is 
the  surgeon's  duty,  so  far  as  in  him  lies,  to  select  that  form  of  operation 
the  unavoidable  shock  of  which  that  patient  will  be  able  to  withstand. 
Ability  to  so  select  this  operation  comes  to  the  surgeon  as  the  result 
of  experience,  and  is  with  difficulty  learned  from  a  text-book.  It 
should,  however,  be  the  surgeon's  desire  always  to  aim  in  the  direction 
of  safety,  remembering  that  excellent  motto  '^  primum  non  nocere." 
In  the  case  of  very  weak  patients  even  an  exploration  may  seem  con- 
tra-indicated; in  others,  gastrostomy,  jejunostomy,  or  even  gastro- 
enterostomy can  be  performed,  and  a  radical  operation,  when  in- 
dicated, may  be  postponed  until  some  strength  shall  have  been  gained 
by  forced  feeding. 

When  the  operation  has  once  been  undertaken,  the  actual  tech- 
nique of  its  performance  will  influence  very  materially  the  develope- 
ment  of  shock.  We  always  lay  great  stress  on  maintaining  the  natural 
heat  of  the  body.  To  this  end  the  patient  should  wear  a  jacket  of 
cotton  wadding,  and  his  lower  extremities  should  be  similarly  clothed. 


414  Complications  and  Sequels. 

In  addition  to  these  precautions,  there  has  been  in  use  for  several 
years  at  the  German  Hospital  a  hot- water  bed  which  covers  the 
entire  top  of  the  operating  table.  These  measures  joined  to  the  tonic 
treatment  to  which  the  patient  has  been  submitted  during  the  day  or 
so  immediately  preceding  the  expected  operation,  w^ill  in  the  vast 
majority  of  cases  prevent  the  occurrence  of  shock.  Indeed,  recently 
we  have  observed  that  patients  recover  as  blithely  from  even  extensive 
gastrectomies  as  they  do  from  an  "interval"  operation  for  appendi- 
citis. When  the  bodily  heat  is  thus  maintained,  and  when  the  surgeon 
eventrates  no  viscera  except  those  immediately  concerned  in  the 
operative  procedure,  the  actual  duration  of  the  operation  seems  to  have 
little  tendency  to  produce  shock,  at  least  in  the  case  of  chronic  lesions. 
Five  minutes  more  consumed  in  an  operation  will  very  rarely  be 
prejudicial  to  the  patient,  and  will  certainly  enable  the  surgeon  to  do 
the  operation  more  thoroughly,  and  therefore  with  more  prospect  of 
ultimate  success,  than  if  he  is  continually  trying  to  establish  a  record. 
We  regard  thirty  minutes  as  a  short  time  to  spend  in  doing  a  gastro- 
jejunostomy, and  are  not  at  all  ashamed  of  taking  more  than  twice  as 
long  in  difficult  cases  of  gastric  surgery. 

Hemorrhage  predisposes  to  shock.  The  surgeon,  however,  who 
pursues  a  definite  plan  in  his  gastric  operations,  and  has  the  necessary 
accjuaintance  with  the  anatomy  of  the  parts,  is  not  apt  to  encounter 
uncontrollable  hemorrhage.  Indeed,  in  all  typical  operations  there 
should  be  no  bleeding,  as  every  blood-vessel  is  clamped  or  tied  before 
it  is  divided.  Yet  where  the  adhesions  are  very  dense,  and  where 
the  anatomical  landmarks  are  with  difficulty  distinguishable,  rather 
profuse  hemorrhage  may  be  encountered.  The  senior  author  has  been 
forced  to  abandon  a  gastrectomy  for  cancer,  and  resort  to  gastro- 
jejunostomy, on  account  of  furious  hemorrhage  among  pyloric  ad- 
hesions. 

Pneumonia. — Among  the  German  Hospital  patients  there  were  no 
deaths  from  pneumonia.  One  patient  with  phthisis,  on  whom  gastro- 
jejunostomy was  done  (July  15,  1907)  for  dilatation  of  the  stomach,, 
developed  cedema  of  the  lungs  on  the  eighth  da}-  after  operation,  when 
convalescence  had  already  set  in.  We  attribute  the  absence  of  pneu- 
monia as  a  postoperative   complication  largely  to  the  precautions,. 


Pneumonia.  415 

already  mentioned,  which  are  taken  against  chilling  the  patients ;  but 
chiefly  to  the  semi-sitting  posture  assumed  as  soon  as  the  effects  of  the 
anaesthetic  pass  off. 

It  is  well  known  that  pneumonia  is  more  liable  to  follow  operations 
in  the  region  of  the  upper  abdomen  than  those  in  the  pelvis ;  and  this 
predisposition  has  been  attributed  to  various  causes.  The  anaes- 
thetic could  have  no  more  harmful  influence  in  one  case  than  in  the 
other;  indeed,  according  to  Krecke,  as  long  ago  as  1901  v.  Mikulicz 
reported  a  much  higher  mortality  from  pneumonia  after  gastric 
operations  under  local  anaesthesia  than  when  a  general  anaesthetic 
was  employed.  However,  it  is  certainly  well  for  the  anaesthetist 
to  bear  in  mind  that  the  visceral  peritoneum  is  insensitive  (Len- 
nander),  and  that  when  once  the  abdomen  has  been  opened,  com- 
paratively light  anaesthesia  is  required  until  the  time  comes  for  closing 
the  incision  in  the  abdominal  wall.  In  spite  of  its  irritating  effects 
on  the  lungs,  we  have  no  hesitation  whatever  in  expressing  our 
preference  for  ether  over  chloroform  as  the  anaesthetic  in  these  cases. 
We  always  administer  it  by  the  so-called  "open,  drop  method." 

Kelling  holds  that  post-operative  pneumonia  in  these  cases  is 
produced  either  by  inhalation  or  by  direct  infection  through  the 
diaphragm;  and  he  remarked  its  much  greater  frequency  in  malig- 
nant and  infectious  conditions,  than  in  cases  of  simple  pyloric  stenosis 
or  gastric  dilatation.  Others  have  taught  that  the  incision  in  the 
epigastric  region  of  the  abdomen  interfered  with  deep  breathing  after 
the  operation,  the  patient  restricting  his  respiratory  excursions  as  far 
as  possible  on  account  of  pain,  and  that  in  this  way  the  smaller  bron- 
chial tubes  became  clogged  with  mucus,  hypostatic  congestion  was 
induced,  and  the  onset  of  pneumonia  favoured.  To  prevent  respira- 
tory difficulty  during  the  operation,  we  have  the  patient's  arms  laid 
beside  him  on  the  table,  never  pinned  up  over  his  chest. 

Since  surgeons  have  adopted  the  habit  of  sitting  their  patients  up 
in  bed  soon  after  the  operation,  the  prevalence  of  post-operative 
pneumonia  in  gastric  cases  has  markedly  diminished;  and  thus  this 
practice,  begun  with  the  erroneous  idea  that  the  stomach  was  emptied 
by  gravity,  has  been  productive  of  good  results,  in  spite  of  its  mistaken 
purpose. 


4i6  Complications  and  Sequels. 

As  urged  by  Robson,  it  is  well  to  direct  these  patients  to  inhale 
deeply  three  or  four  times  every  hour  or  so,  in  the  hope  that  thus 
pneumonia  will  be  prevented,  by  ridding  the  terminal  bronchioles  of 
accumulated  secretion. 

It  has  long  been  our  belief  that  the  injudicious  use  of  saline  solu- 
tion intravenously,  as  a  remedy  or  supposed  preventative  of  shock, 
had  a  tendency  to  predispose  to  pulmonary  complications,  and 
especially  to  oedema  of  the  lungs.  No  one  can  dispute  its  value  in 
hemorrhage;  but  when  care  is  taken  to  prevent  the  dissipation  of 
bodily  heat  it  is  very  exceptional  indeed  in  our  experience  for  patients 
to  be  so  shocked  during  any  operation,  unattended  by  hemorrhage, 
as  to  require  the  use  of  saline  solution  intravenously. 

Should  pneumonia  unfortunately  develope,  no  time  should  be 
lost  in  applying  dry  cups  to  the  patient's  chest,  and  adopting  vigorous 
medical  treatment. 

Peritonitis. — Among  the  German  Hospital  patients  there  were 
eight  deaths  from  peritonitis — two  patients  in  the  benign  series,  and 
six  among  the  malignant  cases.  In  the  patients  with  benign  disease, 
the  primary  operation  had  been  a  posterior  gastro-jcjunostomy  with 
long  loop  (the  first  operation  in  1902,  the  second  in  1905);  in  both  a 
secondary  entero- anastomosis  was  done  on  account  of  the  develope- 
ment  of  the  cir cuius  vitiosus;  and  in  both  leakage  occurred  after  the 
second  oj^eration,  in  which  the  Murphy  button  was  employed,  and 
death  followed  some  days  later  from  peritonitis.  This  form  of 
operation  (long  loop)  has  not  been  employed  since  September,  1905, 
and  the  use  of  the  Murphy  button  is  avoided  whenever  possible. 

Simplification  of  technique,  and  more  especially  the  popularization 
of  rubber-covered  clamps  in  abdominal  surgery,  has  nearly  eliminated 
peritonitis  as  a  post-operative  cause  of  death  in  benign  diseases  of 
the  stomach.  Occasionally,  to  be  sure,  a  death  after  o] juration  is  en- 
countered from  the  subsequent  perforation  of  a  gastric  or  duodenal 
ulcer;  but  these  are  very  rare  cases,  as  arc  also  the  cases  in  which 
peptic  ulcer  of  the  jejunum  developes  and  perforates  before  convales- 
cence is  established. 

Among  the  malignant  cases  at  the  German  Hospital,  there  were 
four  deaths  from  peritonitis  among  the  j)alliative  operations  (2  in 


Peritonitis.  417 

1905,  I  in  1906,  and  i  in  1907) ;  and  two  deaths  from  this  cause  among 
the  partial  gastrectomies,  both  in  1905.  As  the  number  of  operations 
done  has  increased  year  by  year,  it  is  to  be  hoped  that  peritonitis  is 
being  gradually  eliminated  in  these  cases  also.  But  it  cannot  be 
denied  that  peritonitis  is  much  more  to  be  feared  in  malignant  than  in 
non-malignant  disease,  and  there  probably  always  will  be  a  small  pro- 
portion of  deaths  due  to  unavoidable  peritonitis.  In  the  first  of  the 
above  cases  (Feb.  3,  1905),  the  operation  was  a  posterior  gastro- 
jejunostomy with  long  loop,  with  primary  entero- anastomosis  by  a 
Murphy  button ;  the  patient  died  on  the  sixth  day,  and  at  autopsy  an 
abscess  was  found  between  the  loops  of  small  intestine  concerned  in 
the  entero-anastomosis,  thus  making  the  third  fatal  case  to  be  at- 
tributed to  the  use  of  the  Murphy  button.  In  the  second  case  (Dec. 
14,  1905),  the  modern  operation — posterior  short  loop  gastro-jejun- 
ostomy — was  done,  and  the  patient  died  on  the  eleventh  day  from 
perforation  of  a  jejunal  ulcer  on  the  proximal  side  of  the  gastro- 
enterostomy. In  the  third  case  (March  12,  1906)  the  fatal  result  is  to 
be  attributed  to  the  diseased  condition  of  the  gastric  wall  at  the  site 
of  the  anastomosis.  This  we  think  is  the  element  that  can  never 
wholly  be  eliminated  as  a  cause  of  peritonitis  in  these  cases.  In  the 
patients  treated  by  partial  gastrectomy  it  usually  will  be  possible  to 
cut  so  wide  of  the  diseased  area  that  the  sutures  will  hold  securely; 
but  where  only  a  palliative  operation  is  attempted,  the  surgeon,  rather 
than  do  nothing,  or  rather  than  do  a  jejunostomy,  will  often  be 
tempted  to  make  an  anastomosis  in  a  portion  of  the  stomach  wall  already 
affected,  and  thus  run  the  risk  of  peritonitis  developing.  The  fourth 
and  last  of  the  carcinoma  patients  to  die  from  peritonitis  after  a 
palliative  operation  (April  13,  1907)  had  a  malignant  growth  in- 
volving the  pylorus,  the  gastro-hepatic  omentum,  the  transverse  meso- 
colon, and  the  pancreas,  causing,  in  addition  to  the  pyloric  obstruction, 
a  stenosis  of  the  transverse  colon  and  dilatation  of  the  gall  bladder. 
The  operations  done  were:  posterior  gastro-jejunostomy,  with  short 
loop;  cholecysto- colostomy;  and  entero- colostomy.  Death  occurred 
on  the  fourth  day  from  fibrino-purulent  peritonitis. 

Two  patients  died  from  peritonitis  after  partial  gastrectomy  for 
27 


4i8  Complications  and  Sequels. 

carcinoma.     In  neither  could  any  leakage  of  the  sutured  areas  be 
detected  after  death. 

REFERENCES. 

Deaver:  Annals  of  Surgery,  1908,  i,  894. 
Kelling:   Arch.  f.  klin.  Chir.,  1905,  Ixxvii,  301. 
Graf:   Deutsch.  Zeit.  f.  Chir.,  1907,  xc,  365. 


>    ' 


Vicious  Circle.  419 

II.  The  Vicious  Circle  after  Gastro-jejunostomy.* — By  the 
Circulus  Vitiosus  was  formerly  understood  a  train  of  post-operative 
symptoms  believed  to  be  due  to  the  continued  escape  of  gastric  con- 
tents by  way  of  the  pylorus,  and  the  return  of  the  duodenal  contents 
into  the  stomach  through  the  afferent  loop  by  way  of  the  gastro- 
intestinal anastomosis.  Fowler  suggested  the  term  reflux  to  indicate 
that  condition  where  the  duodenal  secretions  (afferent  loop)  or  those 
of  the  jejunum  (efferent  loop)  passed  into  the  stomach  through  the 
gastro-intestinal  anastomosis  and  produced  vomiting,  but  where,  for 
one  cause  or  another,  the  gastric  contents  did  not  obtain  access  to 
the  afferent  loop  through  the  pylorus.  Surgeons  have  thus  spoken 
of  the  duodenal  and  the  jejunal  reflux,  or  have  designated  the  latter 
condition  as  intestinal  regurgitation.  In  general,  however,  the  ex- 
pression vicious  circle  has  been  indiscriminately  applied  to  pernicious 
or  persistent  vomiting  after  gastro-jejunostomy;  and  as  our  knowledge 
of  the  normal  physiology  of  the  stomach  has  increased,  and  as  our 
ideas  of  the  mechanism  of  the  operation  of  gastro-jejunostomy  have 
been  very  materially  altered  within  the  last  few  years,  it  is  scarcely 
desirable,  even  were  it  possible,  to  make  a  distinction  in  the  cause, 
where  we  can  perceive  no  difference  in  the  result.  Indeed,  it  is  ex- 
tremely probable  that  in  most  cases  of  gastro-jejunostomy  by  lateral 
anastomosis,  with  open  pylorus,  precisely  the  course  of  events  occurs 
which  is  stated  above  to  have  been  the  supposed  cause  of  the  vicious 
circle. 

A  discussion  of  the  supposed  causes  of  this  condition  is,  however, 
of  historical  interest.  No  less  a  surgeon  than  Terrier  has  tersely  said 
that  it  is  due  to  faulty  operating — in  other  words,  that  it  is  avoidable 
by  proper  technique.  Certain  it  is,  that  with  increased  experience 
the  surgeon  encounters  it  less  often,  and  that  long  series  of  operations 
have  been  reported  by  various  surgeons,  without  having  it  once  occur. 
With  the  modern  operation  of  gastro-jejunostomy  it  is  rarely  if  ever 
seen;  and  although  most  surgeons  have  abandoned  the  anterior 
operation  (save  in  certain  cases  of  carcinoma)  as  well  as  posterior 
operations  with  a  long  afferent  loop,  because  they  believe  these  more 

*  See  John  B.  Deaver,  "The  Vicious  Circle  after  Gastro-enterostomy,"  N.  Y. 
Med.  Jour.,  1906,  i,  26. 


420 


Complications  and  Sequels. 


apt  to  be  followed  by  the  vicious  circle  than  the  short  loop  or  "no 
loop"  method  originated  by  Petersen  and  popularized  among  sur- 
geons of  Great  Britain  and  America  |by  Moynihan,  yet  there  are  still 
a  few  surgeons,  including  Paterson  of  London,  who  persist  in 
employing  anterior  gastro-jejunostomy  and  who  obtain  entirely  satis- 
factory results. 

Ever  since  the  operation  of  gastro-jejunostomy  was  first  done, 
without  premeditation,  by  Wolfler,  in    1881,  surgeons    have  been 

seeking  some  method  by  which 
this  vicious  circle  could  be 
avoided.  It  is  needless  here  to 
describe  all  the  technical  changes 
which  the  operation  has  under- 
gone in  attempting  to  eliminate 
this  complication.  Each  individ- 
ual method  has  been  adopted  to 
overcome  what  the  surgeon  be- 
lieved was  the  cause  of  the  vom- 
iting. Those  who  thought  it  was 
due  to  spur  formation  at  the  site 
of  the  gastro-jejunostomy  wound, 
aimed  to  prevent  this  by  attach- 
ing the  jejunum  to  the  stomach 
for  some  distance  both  above 
and  below  the  opening  (Hadra; 
Lauenstein);  those  who  thouglit 
it  was  due  to  contraction  of  the 
anastomotic  opening  took  meas- 
ures to  insure  its  patency  (Littlcwood;  Moynihan);  those  who 
thought  it  was  produced  by  pyloric  regurgitation,  obliterated  the 
pylorus  (Mayo);  and  those  who  thought  that  it  depended  on  the 
discharge  of  the  contents  of  the  afferent  loop  into  the  stomach,  or  on 
obstruction  to  the  discharge  from  the  afferent  inlo  the  efferent  looj), 
took  measures  to  overcome  this  difficulty — some  doing  an  entero- 
anastomosis  between  the  afferent  and  efferent  loops  (Lauenstein; 
Braun;  Jaboulay),  and  others  still  further  complicating  the  operation 


Fig.  76.— Diagram  to  show  Course  of 
Gastric  and  Duodenal  Contents. 
Black  arrows  indicate  normal  course, 
red  arrows  indicate  course  after  anterior 
gastrojejunostomy  w'ilh  entero-anastomo- 
sis. 


Vicious  Circle.  421 

by  constricting  (Wolfler;  Chaput;  v.  Hacker;  Fowler)  or  actually 
dividing  (Doyen)  the  afferent  loop  between  the  entero-anastomosis  and 
the  gastro-jejunostomy.  But  the  fact  remained  that  not  one  surgeon 
was  able  to  assign  a  satisfactory  cause  for  the  condition,  nor  always 
able  to  avoid  it,  however  great  his  experience  may  have  been  with  the 
operation,  or  with  this  much  dreaded  sequel.  The  theories  of  Chlum- 
skij,  of  Steudel,  and  of  Kelling,  have  all  been  disproved  in  some 
instances;  and  although  we  are  forced  to  the  rather  humiliating  con- 
clusion that  we  do  not  know  definitely  what  the  actual  cause  is,  we  are 
at  any  rate  convinced  that  it  is  best  avoided  by  adopting  a  simplified 
instead  of  a  complicated  technique,  and  by  giving  occasion  for  the  pro- 
duction of  as  few  post-operative  adhesions  as  possible. 

The  theories  suggested  to  explain  the  vicious  circle  may  be  classed 
under  the  following  heads : 

1.  The  presence  of  bile  or  pancreatic  juice  in  the  stomach. 
Although  excessive  amounts  of  these  may  cause  nausea,  acid  eructa- 
tions, and  even  annoying  vomiting,  they  cannot  alone  be  held  suffi- 
cient to  account  for  severe  cases  of  the  vicious  circle.  Dastre's  ex- 
periments on  dogs,  and  operations  of  cholecysto-gastrostomy  by 
Terrier  and  others,  show  that  bile  is  well  tolerated  by  the  stomach; 
while  the  success  of  Moynihan's  well-known  case,  in  which,  for  rup- 
ture of  the  intestine  at  the  duodeno-jejunal  juncture,  the  proximal 
end  of  the  bowel  w^as  closed  and  the  distal  united  with  the  stomach 
(see  p.  340),  thus  forcing  all  the  duodenal  contents  to  traverse  the 
stomach  before  reaching  the  jejunum,  effectually  sets  aside  the  theory 
that  pancreatic  juice  in  the  stomach  is  solely  responsible  for  the 
symptoms.  Indeed,  as  already  remarked,  it  is  extremely  probable,  if 
not  absolutely  certain,  in  most  of  the  gastro-jejunostomies  done  by 
lateral  anastomosis  at  the  present  day,  that  the  secretions  in  the 
afferent  loop  mix  freely  in  the  stomach  with  the  gastric  contents,  and 
really  are  of  benefit  to  the  patient  (p.  103). 

2.  The  location  of  the  anastomotic  orifice  at  some  other  than  the 
"most  dependent  portion"  of  the  stomach.  This  is  assuredly  not 
a  cause,  in  itself,  since  we  now  know,  and  might  have  known  eight 
years  ago,  if  we  had  heeded  the  researches  of  Kelling,  that  the  stomach 
empties  itself  only  by  contraction,  not  by  gravity.     Moreover,  many 


422  Complications  and  Sequels. 

successful  operations  have  been  done  without  regard  to  the  location 
of  the  anastomosis  at  the  "most  dependent  point."  Indeed,  that  point 
where  the  anastomosis  is  made  may  soon  become  the  "most  depen- 
dent point"  by  the  drag  of  the  intestine;  and  yet  what  is  the  most 
dependent  point  when  the  patient  is  erect,  will  not  be  so  when  he  is  in 
bed.  All  of  which  shows  the  folly  which  inspired  surgeons  who  re- 
garded the  stomach  as  a  tin  can  which  to  be  drained  must  have  a  hole 
cut  in  its  bottom,  and  must  then  be  kept  on  end  if  it  were  to  be  kept 
empty. 

3.  The  presence  of  a  long  afferent  loop  has  been  blamed,  but, 
as  already  mentioned,  many  entirely  successful  operations  disprove 
this  theory,  and  we  must  look  elsewhere  for  a  cause. 

4.  Obstruction  at  the  gastro- jejunal  anastomosis,  of  some 
form  or  other,  is,  we  believe,  the  true  cause  of  this  condition.  The 
vicious  circle  was  more  frequent  in  the  earlier  operations  because  the 
surgeon  damaged  the  bowels  and  the  stomach  more,  and  produced 
temporary  paresis,  or  more  lasting  adhesions;  or  because  the  opera- 
tion was  followed  by  the  formation  of  a  spur,  a  kink,  a  valve  of  mu- 
cous membrane,  or  some  other  form  of  mechanical  obstruction. 
Kelling  very  clearly  pointed  out  that  if  the  stomach  was  damaged 
(either  by  the  operation  or  by  previous  disease,  as  in  far-advanced 
cancer  cases),  it  could  not  properly  contract  after  the  gastro-jejunos- 
tomy;  and  that  under  such  circumstances  the  intestines  would  empty 
themselves  into  it.  He  insisted,  moreover,  on  the  gastro-duodenal 
reflex,  by  virtue  of  which  the  gastric  contractions  cease  so  long  as  the 
duodenum  remains  full.  If,  therefore,  there  was  a  patulous  pylorus, 
or  if  by  reverse  peristalsis  the  gastric  contents  gained  access  to  the 
duodenum  (the  afferent  loop),  the  stomach  could  no  longer  empty 
itself  by  peristalsis  until  the  duodenum  was  emptied;  and  if  this  was 
prevented  by  an  obstruction  at  the  site  of  the  anastomosis,  circum- 
stances were  very  favourable  for  the  dcvelopement  of  the  vicious 
circle.  We  will  recur  again  to  this  topic  when  discussing  the  symp- 
toms of  the  vicious  circle. 

The  employment,  then,  of  a  suitable  technique  will  prevent  ob- 
struction to  the  afferent  loop  at  the  gastro-jejunal  anastomosis,  and 


Vicious   Circle.  423 

will  prove  the  correctness  of  Terrier's  contention  that  the  vicious  circle 
is  due  to  faulty  operating. 

The  symptoms  of  the  vicious  circle  usually  do  not  develope  for 
several  days  after  the  operation.  At  first  there  may  be  merely  a  slight 
regurgitation  of  bile-stained  fluid;  later,  when  more  food  is  taken, 
faecal  matter  may  be  vomited,  the  regurgitation  then  taking  place  from 
the  efferent  loop. 

Several  cases  have  come  under  our  observation  in  which  conval- 
escence after  the  gastro-jejunostomy  was  satisfactory,  but  occasionally 
there  would  be  copious  vomiting  of  biliary  matter.  Meals  were  eaten 
with  appetite,  no  discomfort  ensued,  but  three  or  four  hours  after  the 
meal  this  copious  biliary  vomiting  would  occur.  The  patients  did 
not  lose  in  weight.  One  patient  gained  forty  pounds  during  the  first 
year  after  the  gastro-jejunostomy,  but  the  vomiting  of  pancreatic  and 
bilious  fluids  was  so  persistent  and  annoying  that  she  finally  sub- 
mitted to  another  operation.  The  fact  that  these  patients  vomit 
practically  no  food,  that  digestion  is  accomplished  without  special 
discomfort  before  vomiting  occurs,  and  that  they  do  not  lose  in  weight, 
are  all  important  factors  to  be  considered.  We  are  assured  from 
these  facts  that  in  such  cases  digestion  and  assimilation  are  accom- 
plished fairly  well;  but  that  the  excess  of  bile  and  pancreatic  juices  in 
the  stomach  finally  causes  vomiting.  As  has  already  been  pointed  out, 
the  stomach  tolerates  well  a  moderate  amount  of  bile  and  pancreatic 
juice  and  their  presence  in  the  stomach  interferes  in  no  way  with  the 
digestion  or  health  of  the  individual.  In  searching  for  the  explanation 
of  the  mechanism  present  in  the  class  of  cases  just  described,  it  seemed 
to  us  that  the  course  of  events  might  well  be  the  following:  The  form 
of  operation  primarily  employed  was  posterior  gastro-jejunostomy 
with  a  long  afferent  loop.  It  was  probably  the  length  of  the  loop  that 
saved  the  patient's  life.  There  was  formed  an  obstruction  to  the  in- 
testinal canal  at  the  site  of  the  gastro-jejunostomy.  The  duodenum 
and  afferent  loop  became  filled  with  food  and  bile  and  pancreatic 
juice.  Some  food  no  doubt  passed  into  the  efferent  loop,  but  the 
important  point  for  us  just  now  is  that  the  proximal  (afferent)  loop 
became  filled,  either  by  anti-peristalsis  through  the  gastro-jejunostomy 
opening,  or  through  the  pylorus.     When  this  proximal  loop  became 


424  Complications  and  Sequels. 

filled,  stomach  action  ceased,  according  to  the  gastro-duodenal  reflex  of 
Kelling,  to  which  allusion  has  already  been  made ;  hence  there  was  no 
vomiting  soon  after  eating;  and  as  the  proximal  loop  was  long,  it 
held  a  fair  quantity  of  food;  this  food  was  digested  in,  and  was  largely 
absorbed  from  the  proximal  loop;  though  no  doubt  some  food  was 
discharged  from  the  stomach  directly  into  the  distal  (efferent)  loop, 
and  was  digested  in  and  absorbed  from  it.  The  longer  the  proximal 
loop,  the  more  would  it  hold,  and  the  better  would  digestion  in  it  be 
accomplished.  When  the  proximal  loop  w^as  finally  emptied  by 
absorption,  stomach  movements  returned,  and  the  surplus  of  biliary 
and  pancreatic  secretions  which  had  entered  it  from  the  duodenum,  as 
well  as  the  residue  of  food,  if  any  remained,  were  rejected  by  vomiting. 

There  were  sometimes  seen  instances  of  the  vicious  circle  which 
more  imperatively  demanded  relief  than  those  patients  just  mentioned. 
In  such  cases  the  vomiting  was  persistent  from  the  time  of  the  opera- 
tion, emaciation  was  rapid,  and  unless  something  had  been  done 
speedily  to  relieve  the  patients,  they  would  have  died  of  exhaustion 
and  inanition;  in  fact,  all  the  symptoms  of  a  high  intestinal  obstruc- 
tion were  present. 

The  treatment  should  at  first  be  palliative.  The  patient  should 
be  sat  up  in  bed,  the  stomach  w^ashed  out,  and  all  food  by  the  mouth 
stopped.  Nutritive  enemata  should  be  employed  if  mouth  feeding 
cannot  be  resumed  promptly.  When  vomiting  has  been  absent  for 
twenty-four  or  thirty-six  hours,  a  very  little  liquid  food  may  be  given 
by  mouth — a  drachm  every  hour  or  two;  but  this  must  again  be 
stopped  if  the  vomiting  reappears.  In  the  less  severe  cases  it  is  some- 
times sufficient  to  employ  lavage  every  second  or  third  day;  light  diet, 
in  small  quantities,  being  taken  meantime.  We  have  known  a  patient 
content  to  li\c  in  this  way  for  some  months. 

If  a  cure  is  not  spontaneously  cA'cctcd  thus,  or  immediately  if  the 
sym[;toms  are  urgent,  the  abdomen  should  be  reopened,  and  mechan- 
ical correction  of  the  oljstruction  aUemj)k'(l.  (^i^cralion  should  not 
be  postponed  .so  long  that  the  patient's  strength  will  not  be  sufficient 
to  stand  the  shock;  and,  on  the  other  hand,  too  extensive  an  operation 
should  not  be  employed  on  such  debilitated  ])aticnts. 

The  following  case,  whi(  h  has  been  ])uhlislK'(l  (.■Iscwherc  in  detail 


Vicious  Circle.  425 

by  Dr.  Deaver,  is  quoted  here  as  illustrating  many  points  of  im- 
portance in  this  connection. 

A  young  woman  of  24  years,  who  for  three  years  had  presented  symptoms  of 
gradually  increasing  pyloric  obstruction,  was  operated  on  at  the  German  Hospital, 
by  Dr.  John  B.  Deaver,  July  8,  1903.  Numerous  adhesions  were  found  about  the 
neck  of  the  gall-bladder  and  duodenum.  The  gall-bladder  was  normal,  but  slightly 
distended;  the  stomach  was  slightly  enlarged,  somewhat  proptosed,  and  the  pylorus 
was  thickened.  A  posterior  trans-mesocolic  gastro-jejunostomy  was  done,  with  sutures, 
the  afferent  loop  being  about  ten  inches  long. 

The  patient  did  well  and  was  free  from  vomiting  for  five  days.  On  July  13th, 
700  cc.  of  dark  green  bile  were  vomited;   her  general  condition  was  good. 

July  15th.  Patient  vomited  bile  during  the  night.  Appetite  good,  feels  better 
than  she  has  in  years.     Stitches  removed.     Wound  healed. 

July  17th.     Patient  vomited  bile  with  small  portion  of  fsecal  matter. 

July  i8th.  During  early  morning  the  patient  vomited;  vomitus  stercoraceous 
in  character,  about  300  cc. ;  and  an  intestinal  obstruction  was  believed  to  have  taken 
place,  necessitating  a  second  operation. 

Second  operation,  July  18,  1903  (ten  days  after  the  first  operation).  Omentum 
found  adherent  to  abdominal  scar;  adhesions  separated,  and  omentum  and  trans- 
verse colon  were  turned  upward.  This  reflection  upward  carried  several  coils  of 
small  bowel  along,  and  it  was  found  that  the  proximal  and  distal  Hmbs  of  the 
anastomosed  loop  were  firmly  adherent  to  the  posterior  layer  of  the  transverse 
mesocolon,  interfering  to  a  marked  degree  vnth  the  peristalsis  of  the  bowel.  The 
adhesions  were  all  separated,  and  the  denuded  surfaces  were  inverted  with  silk 
sutures,  or  covered  with  Cargile  membrane.  The  gastro-jejunostomy  was  appar- 
ently perfect.  An  entero-enterostomy  was  then  performed,  by  sutures,  15  cm.  (six 
inches)  from  the  gastric  anastomosis. 

There  was  some  vomiting  of  green  material  upon  the  two  days  following  opera- 
tion, but  this  stopped  upon  the  use  of  lavage. 

July  25th.     Stitches  removed,  wound  healed. 

July  26th.  Patient  vomited  twice  about  300  cc.  of  light  greenish  material. 
Wine  of  ipecac,  10  drops  every  hour,  was  given. 

July  27th.     No  vomiting. 

July  31st.     Ipecac  stopped. 

Aug.  2nd.  Vomited  300  cc.  of  light  green  material  about  10  p.  m.  Vomiting 
could  not  be  attributed  to  anything  eaten.  Given  10  drops  of  wine  of  ipecac  every 
two  hours  during  day. 

Aug.  7th.     Vomited  small  quantity  of  yellow  material.     Ipecac  stopped. 

Aug.  12th.  Discharged.  Condition  fine;  is  gaining  weight,  and  has  not  vomited 
since  Aug.  7th. 

On  Sept.  14,  1903,  this  patient  was  readmitted  to  the  German  Hospital.  She 
stated  that  on  Aug.  i6th,  four  days  after  her  discharge,  vomiting  had  recommenced, 
at  first  of  bile,  and  later  of  food;  and  bile.  When  admitted  she  vomited  everything 
given  by  mouth,  and  large  quantities  of  thick,  ropy,  dark  green  material,  vrith  a  very 
strong  odour.     Feeding  by  rectum  was  begun,  but  the  patient  continued  to  vomit  the 


426  Complications  and  Sequels. 

thick,  dark  green  material,  containing  large  quantities  of  bile.  On  washing  out  the 
stomach  large  quantities  of  the  same  material  were  obtained.  She  was  well  nourished, 
notwithstanding  the  vomiting,  pro\'ing  that  the  food  must  have  been  digested  in  great 
part,  especially  as  the  patient  did  not  seem  to  have  lost  much  weight.  Examination 
of  the  eyes  was  negative;  the  pelvic  organs  were  normal;  and  no  constitutional 
cause  for  the  vomiting  coxild  be  found. 

Third  Operation,  Sept.  19,  1903.  The  omentum  was  found  universally  adher- 
ent, and  there  were  dense  adhesions  between  the  coils  of  bowel.  The  gastro-jejun- 
ostomy  was  exposed,  and  the  opening  found  to  be  freely  patent.  The  entero- 
enterostomy  was  exposed,  some  difficulty  being  encountered  in  distinguishing  the 
anastomosis  by  reason  of  the  numerous  adhesions.  When  these  were  separated 
the  anastomosis  was  found  to  be  in  perfect  condition,  with  some  sacculation. 
Adhesions  were  further  separated  throughout  the  abdominal  cavity.  The  entire 
omentum  was  ligated  and  cut  away.  The  gall-bladder  was  found  normal  in  size, 
numerous  adhesions  surrounding  it;  the  stomach  was  normal  in  size.  By  means 
of  a  pedicle  needle  a  piece  of  silver  wire  was  passed  around  the  pylorus  and  tied. 
The  abdominal  cavity  was  filled  with  normal  salt  solution,  and  the  abdominal  wound 
closed  by  tier  suture.  The  patient  was  shocked,  the  pulse  being  barely  perceptible 
at  the  close  of  the  operation.  An  intravenous  injection  of  sahne  solution  was  given 
before  she  left  the  operating  room. 

Sept.  20.     Patient  vomited  bile  several  times  during  the  day. 

Sept.  22.  Buttermilk  ordered.  Patient  feels  somewhat  distressed  in  the  epi- 
gastric region,  no  vomiting. 

Sept.  23.     Patient  feels  well;    no  epigastric  distress. 

Sept.  29.     Eating  light  diet.     No  nausea  or  distress. 

Oct.  10.     Patient  vomited  after  breakfast. 

Oct.  11-15.  Patient  vomited  several  times  each  day;  complained  of  some 
abdominal  pain;  there  was  some  tympanites.  For  symptoms  of  obstruction,  it 
was  determined  the  next  day  to  re -open  the  abdomen. 

Fourth  Operation,  Oct.  16, 1903.  A  coil  of  small  intestine  was  found  closely  adherent 
to  the  parietal  peritoneum.  The  intestines  were  found  universally  adherent  to  each 
other,  and  to  the  remains  of  the  omentum,  binding  together  the  transverse,  ascending 
and  descending  colon  and  sigmoid  flexure,  and  various  loops  of  small  intestine,  one 
to  another.  No  portion  of  the  bowel,  excepting  about  five  feet  of  the  ileum,  was 
free  from  adhesions.  The  adhesions  were  separated,  bleeding  points  ligated,  and 
all  denuded  surfaces  covered  with  Cargile  membrane.  The  entcro-cnterostomy 
and  the  gastro-jejunostomy  were  examined  and  found  patulous.  At  no  portion  were 
the  intestines  collapsed  or  unduly  distended.  The  abdomen  was  closed  by  through- 
and-through  sutures  of  silkworm  gut. 

Oct.  17.     Much  vomiting. 

Oct.  19.     No  vomiting. 

Oct.  29.     Sutures  removed;  wound  healed. 

Nov.  2.     Patient  allowed  to  sit  up  in  a  chair.     No  vomiting;    feels  strong. 

Nov.  9.     Patient  walking  about. 

Nov.  13.     Patient  went  home. 

The  patient  was  at  home  for  ten  days  when  she  again  began  to  vomit  as  before: 
in  the  morning  bile;    later  in  the  day  particles  of  food;    would  vomit  two  or  three 


Vicious  Circle.  427 

times  every  day.  On  re -admission  her  nutrition  was  good.  On  the  abdomen 
were  two  scars  of  former  operations.     SHght  distension  of  the  stomach. 

Fifth  Operation,  Dec.  7,  1903.  An  incision  seven  inches  long  was  made,  dis- 
secting out  the  last  cicatrix.  On  opening  the  peritoneum  many  adhesions  were 
found  between  intestines  and  under  surface  of  incision.  Universal  adhesions  were 
present  throughout  the  intestinal  canal;  these  were  carefully  dissected  free,  and  two 
holes  in  the  intestine,  which  were  accidentally  made,  were  closed  with  sutures  of 
silk.  Abdomen  was  filled  with  salt  solution,  and  wound  closed  with  through-and- 
through  sutures  of  silkworm  gut. 

Jan.  14,  1904.  Patient  apparently  entirely  well.  She  remained  in  good  health 
for  one  year,  and  then  died  of  unknown  cause,  but  with  no  gastric  symptoms. 

This  unfortunate  woman,  therefore,  had  undergone  five  operations, 
one  after  the  other,  for  the  rehef  of  severe  vomiting.  An  entero- 
anastomosis  and  an  occlusion  of  the  pylorus  both  had  failed  to  relieve 
her  condition.  Every  cause  for  vicious  circle  or  for  jejunal  reflux 
seemed  to  have  been  eliminated,  except  the  influence  of  adhesions, 
which  were  encountered  at  each  operation.  The  patient  gained  in 
weight  even  while  vomiting,  indicating  that  the  digestive  power  was 
not  seriously  impaired. 

The  senior  author's  experience  with  the  vicious  circle  embraces 
ten  cases,  which  may  be  thus  classified : 

1.  Among    25    operations    of    posterior    gastro-  ]   ^^^M     P^^l^^f^     developed     the 

^                -.1      1             a        4-    ^  J           VICIOUS   Circle;     q   of  these  re- 

leiunostomy,    vnth    long    afferent    loop,  and    >                   ,           j           j-  j        r^ 

■"  -,1,      .       --^               ,        °       .          ■         ^  covered,     and     ^     died,     after 

without  primary  entero-anastomosis.  ,  '               r- 

^           ■'  J        secondary  operations. 

2.  Among    19    operations    of    posterior    gastro-  1    ^  ^-     i.       t  j  u 

*?      ^        .,1      ,  a        ^     -i  J       One  patient,  who  was  cured  by 

jejunostomy     vwth    long    afferent    loop,     and    >  j  ^-  ^ 

with  primary  entero-anastomosis.  J  'T    P  ■ 

3.  Among    72    operations    of    posterior    gastro-  \  One  patient,  who  was   cured  by 
jejunostomy  with  short  loop.  /       secondary  operation. 

Probably  no  more  forcible  comment  is  needed  on  the  disadvan- 
tages of  the  long  loop  posterior  gastro-jejunostomy. 

The  eight  patients  in  the  category  where  no  primary  entero- 
anastomosis  was  done,  who  developed  the  vicious  circle,  were  re- 
operated  on  at  intervals  varying  from  four  days  to  one  year  after  the 
primary  operation.  In  six  cases  an  entero-anastomosis  was  done  at 
the  secondary  operation;  four  of  these  six  patients  were  thus  re- 
lieved of  their  symptoms,  but  the  remaining  two  patients  died  after 
the  secondary  operation  from  peritonitis  due  to  leakage  of  the  Murphy 


428  Complications  and  Sequels. 

button  employed  in  making  the  anastomosis.  The  seventh  patient 
was  treated  (April,  1904)  by  resection  with  end-to-end  anastomosis  by 
suture  of  the  distended  alTerent  loop,  thus  converting  the  operation 
into  one  of  the  modern  short  loop  gastro-jejunostomies;  but  this 
patient  died  two  days  after  this  secondary  operation,  of  exhaustion. 
The  last  of  these  eight  patients  was  operated  on  for  the  vicious  circle 
one  year  after  gastro-jejunostomy  by  this  method  (posterior  long 
loop,  without  entero-anastomosis)  had  been  done  in  another  hospital 
by  another  surgeon.  In  this  patient  relief  was  obtained  by  the 
performance  of  an  entero-anastomosis,  ligation  of  the  pylorus,  and 
ligation  of  the  afferent  loop  (Fowler).  She  was  last  heard  from  more 
than  two  years  after  this  secondary  operation,  and  was  in  good  health, 
and  feeling  much  better  than  before  this  last  operation,  though  still 
somewhat  troubled  by  gastric  symptoms. 

The  only  patient  who  developed  the  vicious  circle  among  the 
series  of  long  loop  gastro-jejunostomies  in  which  a  primary  entero- 
anastomosis  was  done,  was  entirely  relieved  of  his  symptoms  by  a 
secondary  ligation  of  the  pylorus,  employed  three  months  after  the 
primary  operation.  He  was  last  heard  from  two  and  a  half  years 
after  the  secondary  operation,  was  in  excellent  health,  and  had  no 
symptoms  referable  to  the  stomach. 

In  the  third  scries  of  cases  (posterior  gastro-jejunostomy  with  a 
short  loop),  there  was  one  patient,  operated  on  in  December,  1905, 
who  developed  regurgitant  vomiting.  Five  months  later  it  was  found 
at  the  secondary  operation  that  the  gastro-jejunostomy  opening  was 
patent;  that  the  pylorus  was  obstructed,  but  that  the  short  proximal 
loop  did  not  appear  to  be  draining  well.  Finney's  pyloroplasty  was 
therefore  done,  as  well  as  an  entero-anastomosis  between  the  short 
afferent  loop  and  the  efferent  loop  of  the  jejunum.  Recovery  was 
uneventful;  but  although  the  regurgitant  vomiting  was  relieved,  the 
patient  when  last  heard  from,  over  two  years  later,  could  only  be 
classed  among  those  "much  improved"  by  operation.  In  looking 
back  at  this  case  it  seems  not  impossiljle  tliat  it  was  one  of  those  in 
which,  as  pointed  out  by  Mayo,  the  jejunum  has  attached  to  it  for 
some  distance  from  its  origin,  a  peritoneal  fold  running  from  the 
transverse  mesocolon,  and  that  owing   to  failure  to  recognize   this 


Vicious  Circle.  429 

anomaly,  the  operation  instead  of  being  a  short  loop  gastro-jejunostomy 
became  in  reality  a  long  loop  operation.  One  similar  case  has  been 
encountered  since,  but  in  this  the  peritoneal  fold  was  recognized, 
divided,  as  recommended  by  Mayo,  and  the  usual  operation  done, 
with  the  usual  satisfactory  result. 

In  common  with  all  surgeons  who  did  stomach  surger}'  as  long  as 
twelve  or  more  years  ago,  the  senior  author's  earliest  gastro-jejun- 
ostomies  (for  carcinoma)  were  done  on  the  anterior  wall  of  the  stom- 
ach, by  means  of  the  Murphy  button.  It  was  not  long,  however, 
until  the  posterior  operation  was  adopted,  still  employing  the  Murphy 
button.  In  the  anterior  operation  a  long  afferent  loop  of  jejunum  is 
obligatory,  on  account  of  the  necessity  of  spanning  the  transverse 
colon  and  great  omentum;  and,  again  in  company  with  other  surgeons, 
the  senior  author  pursued  the  same  technique  in  performing  the 
posterior  operation,  not  appreciating  at  that  time  the  drawbacks  and 
the  positive  dangers  of  the  long  afferent  loop.  Believing  that  the 
regurgitant  vomiting  observed  in  some  of  these  cases  was  due  to  ob- 
struction at  the  anastomotic  opening,  preventing  the  proximal  (affer- 
ent) loop  of  jejunum  from  freely  emptying  itself  into  the  distal  (effer- 
ent) loop,  the  technique  was  then  changed  so  as  to  include  at  every 
primary  operation  an  entero- anastomosis  between  the  afferent  and 
efferent  loops,  thus  making  sure  that  obstruction  to  the  afferent  loop 
could  not  exist.  This  method  proved  for  a  long  time  satisfactory, 
although  its  performance  consumed  more  time  than  the  simple  gastro- 
jejunostomy alone.  To  make  this  additional  time  as  short  as  possible, 
a  Murphy  button  was  at  first  employed  in  making  the  entero- anasto- 
mosis, but  when  disaster  directly  traceable  to  the  use  of  the  Murphy 
button  occurred,  this  method  was  abandoned,  and  since  that  time 
simple  sutures  have  been  employed. 

Even  while  employing  the  method  of  posterior  gastro-jejunostomy 
with  the  long  loop  and  entero-anastomosis,  we  were,  of  course,  quite 
well  aware  of  the  brilliant  results  of  other  surgeons  from  the  "short 
loop"  and  the  "no-loop"  operations;  but  as  long  as  the  technique 
being  employed  proved  satisfactory,  it  seemed  poor  surgery  to  change 
that  technique  merely  to  keep  in  fashion.  In  the  course  of  time, 
however,  it  came  to  pass  that  a  patient  on  whom  this  operation  had 


430  Complications  and  Sequels. 

been  done,  returned  with  the  vicious  circle.  This  patient,  as  already 
described,  was  entirely  relieved  of  his  symptoms  by  ligation  of  the 
pylorus.  Since  that  time  the  short  loop  operation  has  been  employed, 
and  the  vicious  circle  is  now  never  a  sequel  of  the  operation. 

We  would  recommend,  therefore,  the  following  course  in  the  opera- 
tive treatment  of  the  vicious  circle,  following  posterior  gastro-jejun- 
ostomy  Anth  long  afferent  loop : 

1.  Entero-enterostomy  between  the  afferent  and  efferent  limbs 

of  the  jejunal  loop.     If  this  failed  to  relieve, 

2.  Ligation  of  the  pylorus  should  be  the  next  step,  while 

3.  Occlusion  of  the  afferent  loop  between  the  entero-anastomosis 

and  the  gastro-jejunostomy  may  be  done  as  a  final  step. 
Should  for  any  reason  the  performance  of  entero-enterostomy  be 
peculiarly  difficult,  probably  the  next  best  step  w^ould  be  to  divide 
the  afferent  loop  close  to  the  gastro-jejunostomy,  suture  its  distal  end, 
and  implant  the  proximal  coil  (afferent  loop)  into  the  jejunum  at 
least  eight  inches  below  the  gastro-jejunostomy.  This  would  sup- 
plant the  lateral  anastomosis  by  a  posterior  gastro-jejunostomy  in-Y, 
according  to  the  method  of  Roux. 

REFERENCES. 

Deaver:  Amer.  Jour.  Med.  Sc,  1904,  i,  187. 

Deaver:  N.  Y.  Med.  Jour.,  1906,  i,  26. 

Fowler:  Trans.  Amer.  Surg.  Assoc,  1902,  xx,  335. 

Kelling:    Arch.  f.  klin.  Chir.,  1900,  Ixxii,  i,  288. 

Krecke:   Chir.  Eehandl.  d.  Magenerweiterung,  Munchen,  1903,  S.  136. 

Mayo:  Annals  of  Surgery,  1908,  i,  i. 


Peptic  Ulcer  of  jejunum.  431 

III.  Peptic  Ulcer  of  the  Jejunum  after  Gastro-jejunostomy. 

— This  is  a  rare  sequel.  Among  the  thousands  of  gastro-jejunostomies 
which  have  been  reported  by  surgeons  the  world  over,  Key  (1907)  was 
able  to  find  only  55  instances  recorded  in  which  a  peptic  ulcer  had  been 
certainly  observed.  Moynihan  (1908)  has  collected  60  cases.  It  is 
perhaps  true  that  in  some  patients  the  symptoms  of  gastric  trouble 
which  recur  after  apparent  cure  following  gastro-jejunostomy  may  be 
due  not  to  recurrence  of  the  gastric  trouble,  but  to  an  unsuspected 
peptic  ulcer  of  the  jejunum;  but  until  discovered  at  operation  or  at 
autopsy  this  must  remain  a  pure  supposition,  since  we  have  at  present 
no  means  of  accurately  distinguishing  during  life  the  symptoms  of 
jejunal  from  duodenal  or  gastric  ulcer. 

According  to  Gosset,  whose  excellent  monograph  has  been  freely 
drawn  upon  in  preparing  the  following  account,  it  was  not  until  1899 
(seventeen  years  after  the  operation  of  gastro-jejunostomy  was  first  per- 
formed) that  Braun  reported  the  first  case  of  peptic  jejunal  ulcer, 
which  in  his  patient  developed  one  year  after  gastro-jejunostomy.  The 
first  French  case  was  reported  by  Quenu  in  1902,  and  the  first  in  Eng- 
land by  Mayo  Robson  in  1904.  This  shows  that  it  is  not  a  complica- 
tion of  very  frequent  occurrence,  since  even  before  1904  the  number  of 
gastro-jejunostomies  which  had  been  performed  was  very  considerable; 
and  since  the  case  observed  by  Gosset  himself,  in  1905,  was  only  the 
second  to  be  reported  in  France. 

The  relative  frequency  of  this  sequel  may  be  seen  by  the  following 
figures:  these  have  been  purposely  drawn  from  rather  ancient  sta- 
tistics, both  because  modern  operations  are  seldom  followed  by  this 
comphcation,  and  because  we  prefer  to  exaggerate  rather  than  to 
underestimate  the  occurrence  of  so  fatal  a  catastrophe. 

No.  OF  Pep- 
Operator.  No.  OF  Gastro-  tic  Jejunal 

JEJUNOSTOMIES.  UlCERS. 

Hartmann  (Bull.  Soc.  Chir.  Paris,  1904,  xxx,  198) 131  o 

Kausch  (cited  by  Connell:   Surg.,   Gyn.  and  Obst.,  1908,  i,  39)  160  2 

Kronlein  (Schostak:    Beitr.  z.  klin.  Chir.,  1907,  Ivi,  360) 92  i 

Mikulicz  (cited  by  Robson:  Annals  of  Surg.,  1904,  ii,  186). . ..  136  2 

Moynihan  (cited  by  Connell:  Surg.,  Gyn.  and  Obst.,  1908,  i,  39)  21S  i 

Paterson,  collected  cases  (Lancet,  1906,  i,  491;   574) 295  3 

Robson  (Annals  of  Surg.,  1904,  ii,  186) 166  i 

Total 1198  10 


432  Complications  and  Sequels. 

It  occurs,  therefore,  in  less  than  one  per  cent,  of  gastro-jejunosto- 
mies,  without  regard  to  the  special  technique  adopted.  But  from 
Key's  figures  it  is  very  clear  that  the  method  of  operation  has  a  great 
deal  to  do  with  the  relative  frequency  with  which  peptic  jejunal  ulcer 
developes.     Thus  he  found  that 

After  anterior  gastro-jejunostomy  there  were 33  cases. 

"      posterior  gastro-jejunostomy     "         "     13       " 

in-Y,        "         " 4      " 

"  "  "         with  entero-anastomosis 5       " 

If,  now,  we  recollect  that  in  the  statistics  from  which  his  figures  were 
drawn,  the  Y  operation  was  probably  employed  less  frequently  than 
any  of  the  others;  that  the  operations  of  anterior  gastro-jejunostomy 
probably  did  not  largely  predominate  in  number  over  the  posterior; 
that  in  the  large  majority  of  the  posterior  operations  a  long  afferent 
loop  existed;  and  that  the  posterior  gastro-jejunostomies  with  primary 
entero-anastomosis  probably  very  nearly  equalled  in  number  those  done 
without  this  entero-anastomosis ;  it  then  becomes  very  evident  that  the 
supposed  immunity  of  the  Y-operation  is  more  apparent  than  real, 
and  that  the  anterior  operation  is  more  likely  than  any  other  to  give 
rise  to  the  developement  of  a  peptic  jejunal  ulcer. 

The  site  of  the  peptic  ulcer  of  the  jejunum  was  noted  in  34  cases 
studied  by  Schostak.  In  18  patients  the  ulcer  was  in  the  jejunum 
below  the  site  of  the  gastro-jejunostomy;  in  15  patients  it  was  on  the 
margin  of  the  gastro-intestinal  anastomosis;  and  in  i  patient  it  was  on 
the  margin  of  the  entero-anastomosis. 

The  cause  of  this  fatal  complication  has  always  been  assumed  to 
be  the  action  of  the  hyperacid  gastric  secretions  on  a  portion  of  the 
intestinal  canal  unprotected  by  the  alkahne  secretions  of  the  duode- 
num; and  the  greater  frequency  of  peptic  jejunal  ulcer  after  anterior 
gastro-jejunostomy  and  after  posterior  long  loop  operations  in  which 
no  entero-anastomosis  was  done,  certainly  seems  to  support  this  theory. 
Moreover,  this  complication  has  been  noted,  according  to  Connell,  only 
once  (Lennander),  after  gastro-jejunostomy  for  cancer,  in  which  dis- 
ease gastric  acidity  is  absent  or  much  diminished.  But  we  think 
surgeons,  and  perhaps  pathologists  also,  do  not  sufficiently  realize 
that  peptic  ulcer,  whether  in  the  stomach,  tlie  (luodenum,  or  the  jcju- 


Peptic  Ulcer  of  Jejunum.  433 

num,  is  possibly  as  much  a  symptom  of  disease  as  a  disease  itself;  in 
the  same  way  that  the  ulcerated  Peyerian  patches  of  typhoid  fever  do 
not  themselves  constitute  the  whole  of  the  disease.  Thus  it  is  not  be- 
yond the  bounds  of  possibiKty  for  future  experience  to  show  that 
peptic  ulcers  of  the  jejunum  may  exist  in  immature  state  (hemorrhagic 
ecchymosis,  exulceratio  simplex,  etc.  See  p.  71)  in  some  patients  with 
gastric  ulcer,  even  at  the  time  of  operation;  and  that  therefore  their 
subsequent  developement  into  perforating  or  hemorrhagic  ulcers  may 
occur  in  spite  of,  but  by  no  means  as  a  consequence  of,  the  gastro- 
jejunostomy.* At  present,  however,  this  reasoning  is  purely  theoret- 
ical; and  the  only  chnical  cause  to  which  we  can  safely  refer  is  the  ap- 
parent influence  of  anterior  gastro- jejunostomy  in  producing  this  sequel. 

Among  Gosset's  cases,  29  were  in  men,  only  2  in  women. 

Symptoms  may  arise  within  a  few  days,  or  not  for  many  years. 
The  shortest  interval  noted  was  ten  days;  and  in  one  case  referred  to  by 
Gosset,  the  interval  was  seven  years.  In  a  case  subsequently  reported 
by  Edington  there  was  also  an  interval  of  seven  years.  The  majority 
of  cases  of  perforation  (which  is  usually  the  first  manifestation  of  the 
ulcer)  occur  between  one  and  two  years  after  the  operation.  Gosset 
found  17  cases  within  two  years,  and  10  cases  after  this  period  of  time. 

The  perforation  was  subacute  in  20  cases;  acute  in  8;  while  in  3 
cases  perforation  into  a  hollow  viscus  occurred  (Gosset) . 

Prophylaxis  is  of  more  value  than  are  remedial  measures.  The 
simpler  the  technique  of  the  primary  operation,  the  more  likely  will 
it  be  to  cure  the  gastric  condition,  and  therefore  to  restore  the  patient's 
gastro-intestinal  tract  to  its  normal  condition.  Thus  while  Robson 
observed  one  case  of  peptic  jejunal  ulcer  among  30  anterior  gastro- 
jejunostomies, he  did  not  have  it  occur  at  all  among  300  modern  pos- 
terior operations.  But  in  addition  to  the  employment  of  a  proper 
operation,  it  is  above  all  things  important  for  the  surgeon  to  impress 
on  the  patient  the  fact  that  operation  is  only  one  step  in  the  cure  of 
gastric  ulcer — that,  as  pointed  out  at  p.  160,  operation  is  often  only  a 
mechanical  device  to  allow  medical,  dietetic,  and  other  chemical  meas- 

*  Blanc  and  Moss6  have  qmte  recently  narrated  the  history  of  a  patient  with 
symptoms  resembling  pyloric  obstruction,  which  were  found  at   operation  to  be  due 
to  stenosis  of  the  upper  jejunum  from  ulceration. 
28 


434  Complications  and  Sequels. 

ures  to  become  effective.  If  this  fact  were  constantly  borne  in  mind, 
indiscretions  and  negligences  in  diet  and  in  oral  hygiene  (to  the  latter 
of  which  Robson  attributes  a  very  important  role)  would  be  less  apt 
to  occur,  and  the  possibility  of  jejunal  ulcer  developing  would  be 
correspondingly  diminished. 

The  treatment  is  the  same  as  for  perforation  elsewhere  in  the 
intestinal  tract.  The  prognosis,  however,  is  not  so  good  as  in  cases 
of  gastric  or  duodenal  perforation.  The  history  of  the  previous  opera- 
tion, and  the  more  or  less  subacute  character  of  the  symptoms  in  many 
cases,  may  make  the  surgeon  hesitate  to  intervene  promptly;  and  the 
reserve  strength  of  these  patients  is  apt  to  be  slight. 

If  simple  suture  of  the  perforation  seem,  as  it  usually  will,  inex- 
pedient, probably  the  best  method  of  operation  will  be  that  success- 
fully adopted  in  his  case  by  Robson,  viz.,  excision  of  the  affected  coil  of 
jejunum,  and  performance  of  Roux's  operation. 

Edington  collected  nine  operations,  including  one  by  himself,  for 
acute  perforation  of  a  peptic  jejunal  ulcer;  only  two  patients  recov- 
ered. Gosset  collected  23  operations  for  peptic  ulcer  of  the  jejunum 
following  gastro-jejunostomy;  19  of  these  patients  recovered,  some  of 
them  only  after  several  operations  had  been  performed.  Among 
these  23  operations  noted  in  Gosset's  monograph,  there  were  3  acute 
perforations,  with  one  death,  the  cause  of  the  peritonitis  being  found  only 
at  autopsy;  there  were  4  subacute  perforations  (perigastric  abscesses), 
which  all  recovered;  and  13  chronic  perforations,  with  2  deaths. 
There  were,  further,  three  instances  in  which  perforation  occurred 
into  another  portion  of  the  intestinal  tract — two  gastro-colic  fistulae, 
implicating  also  the  jejunum,  and  one  case  of  jcjuno-colic  fistula  with- 
out involvement  of  the  stomach. 

REFERENCES. 

Blanc  and  Mosse:   7\nnales  de  Chir.  et  d'Orthop.,  1908,  xxi,  44. 

Connell:   Surg.,  Gyn.  and  Obstet.,  1908,  i,  39. 

Edington:   Glasgow  Med.  Jour.,  1907,  Ixvii,  463. 

Gosset:  Revue  de  Chir.,  1906,  xxxiii,  54;  290. 

Key:    Nord.   Med.  Arkiv,  Stockholm,  1907,  xl,  Surgery,  No.  2;    cited  in 

Jour.  Amcr.  Med.  Assoc,  1907,  ii,  1963. 
Moynihan:  Annals  of  Surgery,  1908,  i,  1051. 
Schostak:  Jieitr.  z.  klin.  Chir.,  1907,  Iv,  360. 


Internal  Hernia.  435 

IV.  Internal  Hernia  after  Gastro-jejunostomy. — This  compli- 
cation is  rarely  observed.  When  a  long  afferent  loop  was  habitually 
used  in  gastro-jejunostomy  there  was  always  a  possibility  that  some 
coils  of  small  intestine  might  slip  between  this  loop  and  the  anasto- 
mosis, and  thus  become  strangulated.  While  more  likely  to  occur 
after  the  anterior  operation,  as  in  Mayo's  case,  it  may  also  follow  pos- 
terior gastro-jejunostomy  with  a  long  loop.  Even  without  an  actual 
hernia,  the  long  loop  has  been  responsible  for  death  in  a  small  number 
of  cases  by  producing  obstruction  through  volvulus  of  the  anasto- 
mosed loop,  or  by  drawing  the  mesentery  so  taut  as  to  strangulate  the 
lower  bowel  beneath  it. 

Another  sequel,  which  has  followed  trans-mesocolic  operations,  is 
the  occurrence  of  a  hernia  through  the  opening  in  the  transverse 
mesocolon  into  the  lesser  peritoneal  cavity.  Hartmann,  Moynihan, 
and  Harte  have  each  had  such  a  case ;  but  since  the  possibility  of  such 
an  event  has  been  recognized  its  occurrence  has  been  prevented  by 
the  nearly  universal  custom  of  suturing  the  edges  of  the  mesocolic 
opening  around  the  gastro-intestinal  anastomosis. 

Two  such  cases  have  come  under  the  notice  of  Dr.  Ashhurst :  In 
the  first  patient  (at  the  Episcopal  Hospital,  in  1902),  death  occurred 
from  strangulation  of  the  small  intestine  between  the  mesentery  of  the 
afferent  loop  and  the  posterior  abdominal  wall.  In  the  second  pa- 
tient (at  the  Pennsylvania  Hospital)  a  hernia  of  the  small  bowels  into 
the  lesser  peritoneal  cavity  took  place  through  an  unsutured  opening 
in  the  transverse  mesocolon ;  though  the  hernia  was  reduced  at  a  sec- 
ond operation,  the  patient  eventually  died. 

REFERENCES. 

Harte:  Records  of  Pennsylvania  Hospital,  Phila. 

Hartmann:  Personal  Communication. 

Moynihan:   Abdominal  Operations,  Phila.,  1905,  p.  169. 


436  Complications  and  Sequels. 

V.  Gastric  Fistulas. — These  are  classified  by  systematic  writers 
as  the  Internal  and  the  External  varieties. 

External  Gastric  Fistula  (Gastro-cutaneous  Fistula). — Lieb- 
lein  and  Hilgenreiner  (loc.  cit.,  S.  420)  in  1905  found  more  than  120 
cases  of  this  unusual  affection  recorded.  The  subject  has  been  more 
recently  studied  by  Patel  and  Leriche.  This  sequel  may  follow  either 
lesions  of  the  stomach  itself,  or  affections  of  neighbouring  organs. 
Among  the  causes  are: 

1.  Traumatisms. — Stab  or  gunshot  wounds  (as  in  Beaumont's 
patient,  Alexis  St.  Martin)  were  more  apt  to  be  followed  by  the  de- 
velopement  of  a  gastro-cutaneous  fistula  in  former  times  when  pa- 
tients were  left  either  to  die  of  themselves,  or  to  recover  in  such  condi- 
tion as  might  be  determined  by  the  natural  course  of  events.  At 
present,  when  practically  all  such  cases  are  subjected  to  immediate 
operation,  this  sequel  is  very  rare.  The  stomach  may  also  be  perfor- 
ated from  within  by  foreign  bodies  which  have  been  swallowed. 
Lieblein  and  Hilgenreiner  refer  to  two  such  cases. 

2.  Gastric  ulcer  is  one  of  the  recognized  causes  of  this  condition. 
It  may  result  from  perforation  when  the  stomach  is  adherent  to  the 
abdominal  parietes,  or  secondarily,  through  the  external  rupture  of  a 
perigastric  abscess. 

3.  Carcinoma  of  the  stomach  was  noted  as  the  cause  in  26  cases 
among  those  collected  by  Lieblein  and  Hilgenreiner.  As  with  ulcer, 
cancer  may  directly  implicate  the  abdominal  wall,  or  a  perigastric 
abscess  may  form  first.  It  is  also  possible  for  secondary  growths  in 
the  skin,  especially  at  the  umbilicus,  to  perforate  the  stomach. 

4.  Strangulated  her^iia  is  a  very  much  less  frequent  cause  of  gas- 
tric than  it  is  of  intestinal  (faecal)  fistula. 

Among  diseases  of  neighbouring  structures,  which  may  cause  fis- 
tulous tracts  to  form  between  the  stomach  and  the  integument,  must 
be  mentioned,  besides  inflammatory  and  malignant  diseases  of  the 
abdominal  wall,  affections  such  as  hepatic  and  sulj])hrenic  abscesses; 
caries  of  the  ribs  or  sternum ;  h}'(latid  cysts;  cysts  of  the  pancreas,  etc. 

Prophylaxis  is  belter  than  cure.  In  very  many  cases  the  only 
treatment  that  can  be  attempted  will  be  palliative;  moreover,  these 
fistula;  not  infrequently  heal  of  themselves.     If  due  to  benign  disease 


Gastric  Fistula.  437 

(perigastric  abscess,  injury,  etc.),  an  operation  may  properly  be  under- 
taken. Billroth,  in  1877,  was  the  first  to  perform  gastrorrhaphy  for 
this  condition.  By  opening  the  peritoneal  cavity  to  one  side  of  the 
fistula,  and  carefully  excluding  all  surrounding  organs  by  gauze  packs, 
it  frequently  will  be  possible  to  dissect  the  fistulous  tract  free,  and  suture 
the  gastric  opening.  In  other  cases  it  may  be  better  to  attempt  the 
closure  of  the  fistula  by  freshening  its  edges,  and  transplanting  a  flap 
of  skin  to  cover  the  defect.  In  patients  who  cannot  be  properly  nour- 
ished on  account  of  persistent  leakage,  jejunostomy  may  be  done. 

Internal  Gastric  Fistula. — As  the  result  of  disease  or  injury  a 
fistula  may  form  between  the  stomach  and  almost  any  neighbouring 
organ,  or  even  with  another  part  of  the  stomach  itself.  The  colon 
is  most  often  involved  (gastro-colic  fistula) ;  but  communications  have 
been  recorded  with  the  duodenum,  oesophagus,  small  intestine,  gall 
bladder;  and  fistulous  tracts  leading  to  structures  within  the  thorax 
(lung,  heart)  have  been  observed  occasionally.  The  majority  of 
these  rare  sequels  of  gastric  disease  are  of  pathological  interest  only. 
A  few,  however,  may  be  benefitted  by  surgical  treatment.  Their  path- 
ogenesis is  much  the  same  as  in  the  case  of  the  external  fistulae. 

Gastro-colic  Fistula. — Lieblein  and  Hilgenreiner  (loc.  cit.,  S. 
437)  collected  95  cases  of  this  form  of  internal  gastric  fistula.  The 
cause  was  recorded  in  65  of  the  84  cases  studied  by  Chavannaz:  47 
were  due  to  carcinoma  (38  to  gastric,  6  to  colic  cancer,  the  site  in  3 
cases  not  being  recorded);  11  were  due  to  ulcer  (7  certainly,  4  only 
probably) ;  5  were  the  result  of  tuberculous  disease  of  the  stomach  or 
colon ;  and  2  followed  the  formation  of  perigastric  abscess. 

The  symptoms  are  fcecal  vomiting  and  lienteric  diarrhoea.  The 
ingested  food,  especially  such  articles  as  vermicelli,  quickly  appear 
in  the  stools  and  the  similarity  of  the  vomitus  and  the  dejections  is 
an  important  sign. 

The  diagnosis  may  be  confirmed  by  distending  the  colon  or  the 
stomach  with  air,  and  finding  that  the  organ  in  communication  be- 
comes distended  at  the  same  time;  or  injection  of  colored  fluids  may 
be  tried.  Such  tests  are  more  apt  to  be  successful  when  made  through 
the  bowel. 

The  prognosis,  without  operation,  is  gloomy.     Chavannaz  refers 


438  Complications   and  Sequels. 

to  two  cases  in  which  the  fistula  is  said  to  have  closed  spontaneously, 
but  neither  patient  was  traced  long  afterward. 

Palliative  treatment  consists  in  administering  opiates  or  purgati^'es 
accordingly  as  there  is  diarrhoea  or  constipation. 

Surgical  treatment  appears  to  have  been  undertaken  in  seventeen 
patients.  Six  of  the  operations  consisted,  according  to  Chavannaz,  in 
opening  a  perigastric  abscess  (2  patients),  exploratory  laparotomy  (3 
patients),  or  gastrotomy  (i  patient).  The  operations  of  greater  inter- 
est may  be  thus  classified : 

1.  Colotomy.  This  operation  is  only  palliative,  and  may  be  un- 
dertaken as  a  last  resort  to  check  fsecal  vomiting,  by  providing  a  false 
anus  above  the  fistula  between  the  stomach  and  colon.  The  emacia- 
tion due  to  escape  of  food  directly  from  the  stomach  into  the  colon 
would  not  be  prevented.  This  operation  was  employed  in  one  pa- 
tient (Edmunds,  1884);  no  improvement  resulted  and  death  occurred 
15  days  later,  the  patient  also  having  cancer  of  the  rectum. 

2.  Jejunostomy.  This  operation  is  also  merely  palliative,  but 
in  cases  of  extreme  emaciation  would  be  of  slightly  more  value  than 
colotomy.  It  has  been  employed  once  (Labhardt  and  Eiselsberg, 
1 901);  the  patient  probably  had  cancer,  but  improved,  and  returned 
to  his  home  one  month  later. 

3.  Separation  of  stomach  from  colon,  with  suture  of  orifices. 
This  undertaking  is  the  most  radical  of  all,  and  may  lead  into  rather 
extensive  resections  of  the  diseased  stomach  or  colon.  It  has  been 
employed  in  four  cases,  as  follows:  (i)  Henschel  and  Reichel,  1894: 
partial  resection  of  gastric  wall,  and  resection  of  portion  of  transverse 
colon,  including  entire  lumen,  for  cancer.  Operation  lasted  three 
hours  and  a  half  and  ended  fatally.  (2)  Fischer,  1888:  resection  of 
abdominal  wall,  of  anterior  wall  of  stomach,  and  of  transverse  colon; 
imjjlantalion  of  duoflcnum  into  remains  of  stomach,  and  fixation  of 
both  ends  c)f  colon  in  abdominal  wound,  for  carcinoma.  In  spite  of 
a  secondary  growth  in  the  liver,  noted  at  the  time  of  operation,  the 
patient  recovered  from  the  operation,  ]i\ed  five  months,  and  died  of 
carcinoma  of  the  liver.  (3)  C/erny,  1902 :  separation  of  gastro-jejuno- 
colic  fistula,  occurring  two  months  after  posterior  gastro-jejunostomy, 
with  suture  of  the  openings  of  the  stomach  and  colon,  and  the  per- 


Gastric  Fistula.  439 

formance  of  a  new  gastro-jejunostomy.  Recovery.  (4)  Kauffmann, 
1905,  separation  of  the  structures  concerned  in  a  gastro-jejuno-colic 
fistula  (occurring  four  years  after  posterior  gastro-entero-anastomosis). 
with  ileo-sigmoidostomy  for  stricture  of  transverse  colon  caused  by 
suture  of  the  two  perforations  in  the  colon.  Time  of  operation,  three 
hours.  Six  days  later  the  abdomen  was  again  opened  for  symptoms 
of  perforation.  These  were  found  to  be  due  to  perforation  of  the 
sigmoid  by  the  button  used  in  making  the  anastomosis.  The  patient 
died  on  the  table  at  the  second  operation. 

4.  Exclusion  of  the  gastro-cohc  fistula.  This  may  be  either  a 
complete  exclusion,  or  a  simple  short-circuiting  operation,  (a) 
Complete  Exclusion.  Three  such  operations  are  referred  to  by 
Chavannaz.  (i)  Zweig  and  Hahn,  in  1900,  made  an  anastomosis 
between  the  transverse  colon  (above  the  fistula)  and  the  sigmoid,  and 
then  occluded  the  colon  on  each  side  of  the  fistula  by  a  pursestring 
suture.  Time  of  operation,  two  hours  and  a  half.  Patient  recovered 
and  was  in  good  health  three  years  later.  (2)  Unruh  and  Garre,  in 
1899,  divided  the  transverse  colon  above  and  below  the  fistula,  closed 
all  four  ends  of  the  colon,  and  then  united  the  transverse  colon  above 
the  fistula  to  the  descending  colon.  The  portion  of  the  colon  involved 
in  the  fistula  was  thus  converted  into  a  diverticulum  of  the  stomach. 
The  operation  lasted  two  hours ;  the  patient  recovered,  and  was  in  good 
health  9  months  later.  (3)  Kelling,  in  1903,  divided  the  transverse 
colon  on  both  sides  of  the  fistula,  closed  the  ends  of  the  gastric  segment 
of  colon  by  purse-string  sutures,  and  did  end-to-end  anastomosis  of  the 
transverse  colon.  His  patient  recovered,  but  died  1 9  months  later  from 
cancer  of  the  stomach. 

(b)  Short-circuiting  has  been  adopted  in  two  cases  mentioned  by 
Chavannaz.  Labhardt  and  Garre,  in  1901,  did  a  'colo- colostomy  of 
the  transverse  colon  above  and  below  the  fistula.  Their  patient  im- 
proved, and  the  faecal  vomiting  stopped.  Chavannaz,  in  1906,  united 
the  ascending  colon  to  the  sigmoid,  for  fascal  vomiting  due  to  can- 
cerous fistula.  The  vomiting  was  not  improved  and  the  patient  died 
in  fifteen  days. 

It  is  interesting  to  note  in  this   connection  that  Mauclaire  pur- 


440  Complications  and  Sequels. 

posely  produced  a  gastro- colic  fistula  with  the  hope  of  relieving  severe 
gastralgia  which  recurred  one  year  after  the  performance  of  a  posterior 
gastro-jejunostomy.  On  reopening  the  patient's  abdomen,  he  found 
the  gastro-jejunal  anastomosis  in  good  condition,  and  determined  to 
do  a  gastro-cohc  anastomosis  because,  in  a  previous  similar  case,  no 
benefit  had  been  derived  from  a  second  (anterior)  gastro-jejunostomy. 
In  his  second  patient  the  pylorus  was  thickened  and  indurated,  but 
there  was  no  open  ulcer.  The  patient  was  much  improved  (!)  by  the 
formation  of  the  gastro-colic  fistula,  but  was  not  cured.  Surely  pylo- 
rectomy  would  have  been  better. 

Jejuno-colic  Fistula. — Gosset  has  recorded  a  successful  opera- 
tion for  this  complication,  caused  by  the  perforation  of  a  peptic  jejunal 
ulcer  two  years  after  posterior  gastro-jejunostomy.  He  separated  the 
jejunum  and  colon,  sutured  the  perforations,  and  did  ileo-sigmoid- 
ostomy  because  of  the  stricture  thus  produced  in  the  colon. 

REFERENCES. 

Chavannaz:   Revue  de  Gyn.  et  de  Chir.  Abd.,  1907,  xi,  527. 

Czerny:   Cited  by  Gosset,  loc.  infra  cit.,  p.  290,  Obs.  xix. 

Edmunds:   Cited  by  Chavannaz,  loc.  cit. 

Fischer:  Centralbl.  f.  Chir.,  1888,  xv,  Beil.,  S.  47. 

Gosset:   Revue  de  Chir.,  1906,  xxxiii,  54.     (Jejuno-colic  fistula.) 

Henschel  and  Reichel:  Cited  by  Chavannaz,  loc.  cit. 

Kauffman:  Cited  by  Gosset,  loc.  supra  cit.,  Obs.  xxvii. 

Labhardt  and  Eiselsberg:   Cited  by  Chavannaz,  loc.  cit. 

Lieblein  and  Hilgenreiner:    Die  Geschwiire  u.  d.  erworbenen  Fisteln  d 

Magen-Darmkanals,     Deutsche     Chir.,    Lieferung    46,    c. 

Stuttgart,  1905,  S.  420;  437. 
Mauclaire:   Cited  by  Dencchau,  Arch.  Gen.  de  Chir.,  1908,  ii,  328. 
Patel  and  Leriche:   Revue  de  Chir.,  1906,  xxxiv,  34. 


Duodenal  Fistula.  441 

•  VI.  Duodenal  Fistula. — This  extremely  fatal  complication  of 
upper  abdominal  lesions  may  follow  either  disease  or  trauma.  Among 
the  latter  must  be  included  operative  injuries,  such  as  are  sometimes 
sustained  in  operations  on  the  bile  passages  (Kraske,  Kehr,  Lilien- 
thal,  Mayo,  Fink,  Berg),  or  on  the  right  kidney  (Schede,  Cackovic). 
Lieblein  and  Hilgenreiner  refer  to  sixteen  cases  of  duodenal  fistula, 
eight  of  which  were  collected  in  1903  by  Cackovic. 

The  causes  are  various.  Perforation  of  an  ulcer  usually  has  pro- 
duced a  fistula  above  the  bile  papilla,  while  operative  fistulae  are  more 
often  below  this  level,  as  are  also  fistulae  the  result  of  rupture  or  gun- 
shot wounds  of  the  duodenum  (see  p.  340).  The  cutaneous  orilice  of 
the  fistula  is  frequently  in  the  right  hypochondrium,  but  if  the 
fistulous  tract  is  retro-peritoneal,  its  outer  opening  may  be  in  one  of  the 
intercostal  spaces  (Steaten,  Gross),  in  the  loin  (Hinton),  or  even  in  the 
right  inguinal  region  (Wagner);  in  Rintel's  case  the  fistula  was  due 
to  tuberculous  peritonitis,  and  was  at  the  umbilicus. 

The  diagnosis  can  be  made  usually  with  comparative  ease,  differ- 
entiation from  gastric  fistula,  the  only  lesion  with  which  it  is  readily 
confused,  presenting  few  difficulties. 

The  prognosis,  unless  the  fistula  is  a  sequel  of  operation,  is  bad. 
Duodenal  fistulse  following  operation,  whether  from  pressure  of  a 
drainage  tube,  from  necrosis  due  to  partial  obliteration  of  the  blood 
supply,  or  to  an  injury  undiscovered  during  the  operation,  usually 
heal  spontaneously.  But  if  the  fistula  is  the  result  of  duodenal  ulcera- 
tion, with  subphrenic  abscess  or  a  long  retro-peritoneal  suppurating 
tract,  emaciation  is  rapid,  and  if  the  patient  does  not  die  of  starvation, 
■  he  is  liable  to  do  so  from  sepsis.  Except  for  several  post-operative 
cases,  we  know  of  no  instance  of  recovery  from  duodenal  fistula. 

The  only  treatment  which  offers  any  hope  of  cure  is  operation. 
Traumatic  lesions  alone  are  suitable  for  suture  (duodenorrhaphy). 
When  the  fistula  follows  ulceration,  much  more  may  be  hoped  for 
from  gastro-jejunostomy  combined  with  unilateral  exclusion  of  the 
duodenum  by  ligation  of  the  pylorus.  This  operation  was  suggested 
by  Cackovic  and  by  Berg  in  1903.  Berg's  first  patient  lived  seventeen 
days;  but  in  his  second  case  he  attempted  to  suture  the  perforation  at 
the  same  time  that  he  did  gastro-jejunostomy;  the  sutures  gave  way, 


442  Complications  and  Sequels. 

and  then  occlusion  of  the  pylorus  was  performed  too  late  to  save  the 
patient.  In  patients  with  extreme  emaciation  jejunostomy  may  be 
performed  with  the  hope  of  doing  a  more  radical  operation  should 
sufficient  strength  be  gained.  Cackovic  tried  this  plan,  but  his 
patient  died  in  two  days. 

Internal  Duodenal  Fistula,  /.  e.,  gastro-duodenal,  duodeno- 
colic,  cholecysto-duodenal,  etc.,  is  so  rare  as  to  be  of  pathological 
interest  only. 

REFERENCES. 

Berg:   Centralbl.  f.  Chir.,  1903,  xxx,  556. 
Berg:  Annals  of  Surgery,  1907,  i,  721. 
Cackovic:  Arch.  f.  klin.  Chir.,  1903,  Ixix,  843. 

Lieblein  and  Hilgenreiner:    Deutsche  Chir.,  Lieferung  46,  c.     Stuttgart, 
1905,  S.  486. 


Subphrenic  Abscess.  443 

VII.  Subphrenic  Abscess. — This  serious  compHcation,  though 
due  to  a  variety  of  causes,  is  in  such  a  large  proportion  of  cases  due 
to  precedent  gastric  or  duodenal  disease,  as  to  render  it  worthy  of 
rather  extended  notice  in  this  volume. 

By  the  term  subphrenic  abscess  is  strictly  understood  only  those 
abscesses  formed  between  the  dome  of  the  diaphragm  and  some  sub- 
jacent organ;  but  as  usually  employed  the  expression  is  made  to 
embrace  practically  every  abscess  which  at  one  portion  or  other  of  its 
circumference  comes  into  contact  with  some  portion  of  the  diaphragm. 
Thus  an  abscess  between  the  left  lobe  of  the  hver  and  the  anterior 
gastric  wall  is  included  among  subphrenic  abscesses  because  of  its 
close  relation  to  the  attachments  of  the  diaphragm  in  the  left  epi- 
gastric and  hypochondriac  regions;  and  one  in  the  lesser  peritoneal 
cavity  will  also  be  included  because,  by  extending  outward  toward 
the  spleen,  or  upward  and  backward  along  the  Spigelian  lobe  of  the 
liver,  it  will  come  into  contact  with  the  diaphragm  in  those  situations. 

The  first  description  of  subphrenic  abscess,  according  to  Free- 
man, was  that  of  Barlow,  in  1845.  ^^  ^^^^  it  was  accurately  described 
by  Bouchard;  and  the  first  operation  was  recorded  by  Volkmann,  in 
1879.  Maydl,  in  1894,  pubKshed  a  monograph  on  the  subject  based 
on  a  study  of  179  cases.  Finkelstein  in  1899  collected  252  cases; 
and  the  subject  has  recently  been  discussed  by  Barnard,  to  whose  ex- 
cellent papers  we  are  glad  to  acknowledge  our  indebtedness  in  pre- 
paring the  present  account. 

A  study  of  the  pathogenesis  of  subphrenic  abscess  is  considerably 
simplified  by  dividing  the  area  beneath  the  diaphragm  into  certain 
dejBinite  anatomical  regions,  as  done  by  Barnard:  "The  under  surface 
of  the  diaphragm  is  marked  out  into  four  peritoneal  spaces  and  two 
cellular  ones.  The  four  peritoneal  spaces  are  separated  from  one 
another  by  the  cruciform  arrangement  of  the  ligaments  of  the  liver— 
namely,  the  coronary,  falciform,  and  the  right  and  left  lateral  liga- 
ments. The  falciform  ligament  divides  the  subphrenic  space  into 
two  parts,  right  and  left.  Each  of  these  is  again  subdivided  into  a 
larger  anterior  and  a  smaller  posterior  part  by  the  corresponding 
lateral  ligament."  The  two  cellular  (extra-peritoneal)  subphrenic 
areas  are  (i)  that  included  between  the  layers  of  the  coronary  liga- 


444  Complications  and  Sequels. 

ment;  and  (2)  that  extending  from  the  cellular  tissues  around  the 
upper  pole  of  the  left  kidney  up  to  beneath  the  left  dome  of  the 
diaphragm.     Barnard  therefore  classifies  the  subphrenic  fossae  thus: 

/     T    Ti-  i_i.    f  I-  Anterior. 
(     I.  Right.  <^    ^    Posterior 

A.  Intra -peritoneal.  \  >         a„v-„„- 

I  "Left.  {^^ss,?;. 

B.  Extra -peritoneal <    ^'  -r3f 

1.  An  abscess  in  the  right  anterior  intra-peritoneal  region  is 
bounded  above  by  the  diaphragm,  below  by  the  right  lobe  of  the  liver, 
on  the  left  by  the  falciform  ligament ;  in.  front  usually  by  adhesions 
between  the  hepatic  margin  and  the  anterior  abdominal  wall;  while 
on  the  right  such  an  abscess  is  frequently  continuous  with  the  right 
kidney  pouch,  from  which  direction  the  infection  has  most  often 
travelled.  Of  27  abscesses  in  this  group,  studied  by  Barnard,  only  6 
were  due  to  perforation  of  gastric  or  duodenal  ulcers;  the  great 
majority  were  caused  by  appendicitis  (10  cases)  or  hepatic  abscesses 
(7  cases). 

2.  The  right  posterior  intra-peritoneal  region  is  continuous,  be- 
tween the  posterior  surface  of  the  right  lobe  of  the  hver  and  the  lower 
ribs,  with  the  right  kidney  pouch  and  subhepatic  fossa.  In  its 
strictly  subphrenic  region  such  an  abscess  would  be  bounded  above  by 
the  diaphragm,  below  by  the  upper  surface  of  the  posterior  portion  of 
the  right  lobe  of  the  liver,  in  front  by  the  right  lateral  ligament,  and 
on  the  left  by  the  reflection  of  parietal  peritoneum  covering  the  right 
surface  of  the  vena  cava  and  becoming  continuous  between  diaphragm 
and  liver  with  the  coronary  and  right  lateral  ligaments  of  the  liver.  Ab- 
scesses in  this  situation  also  are  commonly  due  to  infection  through 
the  right  renal  pouch,  and  so  such  an  abscess  may  sometimes  extend 
beneath  the  right  lobe  of  the  liver,  between  it  and  the  transverse  meso- 
colon, across  the  foramen  of  Winslow  to  the  anterior  surface  of  the 
gastro-hcpatic  omentum,  where  it  will  be  bounded  above  by  the  left 
lobe  of  the  liver,  below  by  the  stomach,  in  front  by  tlic  al)(Iominal  wall 
and  the  diaphragm.  Of  course,  it  is  also  possible,  though  less  usual, 
for  infection  to  travel  in  the  other  direction,  starting  on  the  anterior 
surface  of  the  .stomach,  pa.ssing  to  the  subhepatic  region,  up  the  poste- 


Subphrenic  Abscess.  445 

rior  abdominal  wall,  to  become  again  finally  subphrenic.  This  area 
is  thus  seen  to  be  very  large  and  irregular  in  outline :  it  includes  not 
only  the  region  above  the  right  lobe  of  the  liver,  back  of  the  right 
lateral  ligament,  but  also  the  subhepatic  space,  which  has  its  base  in 
the  lateral  abdominal  wall,  and  its  apex  between  the  left  lobe  of  the 
liver  and  the  anterior  gastric  wall.  Among  Barnard's  76  cases  of  sub- 
phrenic abscess,  this  region  was  involved  in  only  10  cases;  and  in  only 
2  of  these  was  the  cause  gastric  or  duodenal  ulcer. 

3.  Abscess  in  the  left  anterior  intra-peritoneal  region  is  bounded 
above  by  the  diaphragm,  below  by  the  left  lobe  of  the  liver,  on  the 
right  by  the  falciform  ligament,  on  the  left  by  the  spleen,  posteriorly 
by  the  left  lateral  ligament,  and  anteriorly  by  adhesions  between  the 
anterior  surface  of  the  stomach,  the  transverse  colon,  the  great  omen- 
tum, and  the  abdominal  wall.  Below  the  anterior  margin  of  the  left 
lobe  of  the  liver  this  pouch  is  continuous  on  the  right  with  the  sub- 
hepatic pouch,  and  on  the  left  with  the  lumbar  pouch,  from  which  in- 
fection may  reach  it  by  travelling  between  the  spleen  and  the  splenic 
flexure  of  the  colon.  This  left  anterior  intra-peritoneal  sub-diaphrag- 
matic region  is  that  which  is  most  often  invaded  by  gastric  ulcers 
which  perforate  subacutely.  Among  Barnard's  cases,  there  were  30 
instances  of  suppuration  in  this  space,  and  20  of  these  abscesses  were 
due  to  gastric  and  duodenal  lesions  (16  to  gastric  ulcer,  '2  to  gastric 
cancer,  i  to  resection  of  the  stomach,  and  i  to  duodenal  perforation). 

4.  An  abscess  in  the  left  posterior  intra-peritoneal  region  arises  in 
the  lesser  peritoneal  cavity.  The  Spigelian  lobe  of  the  liver,  which 
lies  in  the  roof  of  this  cavity  (see  p.  19),  is  in  contact  with  the  peri- 
toneum covering  the  left  crus  of  the  diaphragm.  This  portion  of  the 
lesser  peritoneal  cavity  is  usually  the  last  to  be  invaded,  so  that  fre- 
quently a  so-called  subphrenic  abscess  in  this  region  will  have  no 
direct  relation  to  the  diaphragm.  The  lesser  peritoneal  cavity  of 
course  communicates  through  the  foramen  of  Winslow  with  the  sub- 
hepatic pouch;  but,  as  is  well  known,  inflammatory  processes  in  this 
region  tend  to  become  encysted  by  the  early  obliteration  of  this  fora- 
men by  adhesions.  It  is  very  rare  for  an  abscess  to  separate  the 
layers  of  the  great  omentum  and  form  a  secondary  omental  abscess. 
The  most  usual  cause  of  suppuration  in  the  lesser  peritoneal  sac  is 


446  Complications  and  Sequels. 

perforation  of  a  gastric  ulcer.  Among  Barnard's  76  cases  there  were 
3  abscesses  in  this  situation:  2  were  due  to  gastric  perforation,  the 
third  being  caused  by  suppuration  of  lymph  nodes  in  the  lesser 
omentum,  secondary  to  cholecystitis.  Michel  and  Gross  in  1904 
collected  44  instances  of  suppuration  in  the  lesser  peritoneal  cavity. 
They  classify  the  causes  thus:  i.  Encysted  hemorrhage  which  has 
become  infected,  due  originally  to  pancreatitis  haemorrhagica  or  to 
trauma.  2.  Directly  from  pancreatitis.  3.  Perforation  of  the  stom- 
ach. 4.  Diseases  of  the  spleen.  5.  General  peritonitis.  Dr.  Ash- 
hurst  has  reported  a  case  of  gastric  ulcer  in  which  perforation  oc- 
curred nearly  simultaneously  on  both  anterior  and  posterior  walls, 
producing  two  subphrenic  abscesses,  one  beneath  the  left  lobe  of  the 
liver,  anterior  to  the  gastro-hepatic  omentum,  and  the  other  in  the 
lesser  peritoneal  cavity. 

5.  An  abscess  in  the  right  extra-peritoneal  subphrenic  region  lies 
between  the  layers  of  the  coronary,  the  two  lateral,  and  the  falci- 
form ligaments  of  the  hver.  The  19  cases  observed  in  Barnard's 
series  were  due  mostly  to  abscess  of  the  liver  or  other  forms  of  hepatic 
disease;  other  recognized  causes  are  affections  of  the  right  kidney, 
retro-peritoneal  appendicular  suppurations,  retro-peritoneal  duodenal 
perforations,  and  occasionally  perforation  of  the  diaphragm  as  the 
result  of  thoracic  disease.  Such  abscesses  may  point  in  the  epigastric^ 
region,  or  rarely  at  the  umbilicus. 

6.  The  left  extra-peritoneal  subphrenic  region  is  usually  infected 
through  the  structures  around  the  spinal  column  or  the  left  kidney. 
Two  of  Barnard's  cases  were  due  to  acute  pcriosteitis  of  the  transverse 
vertebral  processes,  a  third  was  caused  by  an  empyema,  and  "the 
fourth  was  probably  due  to  a  posterior  perforating  gastric  ulcer," 
as  in  the  similar  case  described  by  Robson. 

Cause. — As  may  be  seen  from  the  preceding  paragraphs,  the 
causes  of  subphrenic  abscess  are  many  and  varied.  Among  the  252 
cases  collected  by  P'inkelstein,  67,  or  26.6  per  cent.,  were  due  to  lesions 
of  the  stomach.  From  liis  study  of  76  cases  Harnard  found  that  21 
were  due  to  gastric,  and  5  to  duodenal,  ]K'rforation;  while  12  were 
caused  by  appendicitis,  and  15  by  affections  of  the  liver.  He  con- 
cludes that  perforated  gastric  and  duodenal  ulcers  cause  about  one- 


Subphrenic  Abscess.  447 

third,  appendicitis  about  one-sixth,  hydatid  disease  and  tropical  ab- 
scess of  the  liver  about  one-sixth;  the  remaining  one-third  being  due 
to  miscellaneous  affections. 

Pathogenesis. — We  may  then  briefly  study  the  origin  and  method 
of  infection  in  these  various  classes. 

Gastric  ulcers  most  often  perforate  anteriorly.  If  diffuse 
peritonitis  is  not  at  once  produced,  the  perforation  will  be  subacute, 
protective  adhesions  having  quickly  formed.  Under  these  circum- 
stances the  resulting  abscess  will  occupy  the  apex  of  the  subhepatic 
fossa,  between  the  left  lobe  of  the  liver  above,  the  gastro- hepatic 
omentum  posteriorly,  and  the  stomach  below.  Unless  quickly  re- 
lieved, such  an  abscess  is  prone  to  leak,  producing  secondary  diffuse 
peritonitis,  usually  of  the  progressive  fibrino-purulent  form  described 
by  Mikulicz.  If  neither  leakage  nor  rupture  occur,  the  pus  usually 
will  work  its  way  around  the  anterior  margin  of  the  left  lobe  of  the 
liver,  invade  the  left  anterior  subphrenic  space,  and  form  a  true  sub- 
phrenic abscess.  Although  this  anterior  perigastric  abscess  is  almost 
invariably  the  result  of  subacute  perforation  of  a  gastric  ulcer,  it  may 
occur  on  the  subsidence  of  an  unoperated  diffuse  peritonitis  due  to 
acute  perforation.  Such  a  case  has  recently  been  observed  by  Dr. 
Ashhurst  under  Dr.  T.  R.  Neilson's  care  at  the  Episcopal  Hospital. 
Perforation  of  a  posterior  gastric  ulcer  causes  suppuration  in  the 
lesser  peritoneal  cavity;  very  rarely  has  perforation  on  the  extra- 
peritoneal surface  of  the  stomach  led  to  subphrenic  abscess.  Se- 
quels of  these  epigastric  abscesses  other  than  fatal  peritonitis  are  rare ; 
but  among  the  results  which  are  occasionally  seen  may  be  mentioned 
the  various  forms  of  gastric  fistulse,  already  described  (p.  436) ;  and 
perforation  of  the  pleura,  the  lung,  the  pericardium,  etc. 

Duodenal  ulcers  on  perforation  infect  either  the  right  anterior 
subphrenic  region,  if  intra-peritoneal,  or  the  right  retro-peritoneal 
cellular  tissue,  if  perforation  occurs  on  the  posterior  or  internal  surface 
of  the  bowel.  Intra-peritoneal  infection  has  a  marked  tendency  to 
gravitate  to  the  right  lumbar  region,  and  by  invading  even  the  iliac 
fossa  may  simulate  appendicitis. 

Appendicitis  itself  may  give  rise  to  subphrenic  abscess  in  various 
ways.     Elsberg    collected  73  such  cases,  and  to    these    Eisendrath 


448  Complications  and  Sequels. 

has  recently  added  ^^  others,  including  5  of  his  own.  Intra-peritoneal 
subphrenic  abscess  is  much  more  often  a  complication  of  appendicitis 
than  is  extraperitoneal.  Among  the  106  cases  analyzed  by  Eisen- 
drath,  the  abscess  was  intra-peritoneal  in  two-thirds.  In  the  usual 
variety  the  right  renal  pouch  is  first  affected,  then  the  right  posterior 
intra-peritoneal  subphrenic  space,  including  the  subhepatic  space,  and 
finally  the  right  anterior  subphrenic  space  may  be  invaded  around  the 
right  free  extremity  of  the  lateral  ligament  of  the  liver.  Such  a 
patient  has  recently  been  operated  on  at  the  Episcopal  Hospital  by 
Dr.  Ashhurst.  If  the  appendix  lies  to  the  inner  side  of  the  colon,  in 
front  of  the  mesentery  of  the  ileum  (a  very  unusual  position),  the  apex 
of  the  subhepatic  space  may  be  infected  directly,  without  involvement 
of  the  right  renal  pouch.  Extra-peritoneal  subphrenic  abscess  as  the 
result  of  appendicitis  may  occur  by  continuity  of  tissue,  or  secondarily 
through  invasion  of  the  liver  after  suppurative  pylephlebitis.  The 
same  course  of  events  may  of  course  occur  as  the  result  of  gastric 
disease.  Eisendrath  found  recorded  only  six  left-sided  cases  of  sub- 
phrenic abscess  due  to  appendicitis. 

Hepatic  abscess  frequently  becomes  subphrenic  by  the  process 
of  pointing  of  an  abscess  through  the  convex  surface  of  the  liver. 

Diagnosis. — According  to  Barnard,  in  aiming  to  arrive  at  a 
diagnosis  in  cases  of  suspected  subphrenic  abscess,  special  attention 
should  be  paid  to  the  following  points : 

1.  The  Previous  History  of  the  Patient. — The  usual  causes  of  the 
condition,  e.  g.,  gastric  or  duodenal  ulcer,  appendicitis,  hepatic  ab- 
scess, dysentery,  etc.,  must  be  studied. 

2.  The  Character  oj  the  Onset  \?,\m\ior\Q.r\t.  If  the  symptoms  were 
acute,  the  abscess  probably  is  intra-peritoneal ;  but  if  insidious  in  their 
origin  it  is  more  likely  to  be  situated  extra- peritoneally,  or  in  the  lesser 
peritoneal  cavity. 

3.  The  Signs  oj  Pus  in  general  should  be  searched  for:  elevation 
of  temperature,  persistent,  even  if  slight;  chills;  emaciation;  thirst; 
leukocytosis;  etc.  Other  possiljle  regions  of  suj)[)uralion  should  be 
excluded. 

4.  Abdominal  Signs  and  Symptoms. — These  include  bulging, 
immobility    during    respiration;     tenderness,    rigidity;     dulness,    or 


Subphrenic  Abscess.  449 

tympany  due  to  the  perforation  of  an  air-containing  viscus.     A  swell- 
ing due  to  subphrenic  abscess  is  immobile  because  fixed  by  adhesions. 

5.  Thoracic  Signs  and  Symptoms. — These  were  present  in  56 
out  of  the  76  cases  of  subphrenic  abscess  studied  by  Barnard.  The 
most  important  are:  dulness,  associated  with  upward  displacement 
of  the  lung;  diminution  or  absence  of  breath  sounds,  vocal  resonance, 
and  vocal  fremitus.  Occasionally  dulness  on  percussion  may  be 
associated  with  tubular  breathing  and  increased  vocal  resonance. 
Amphoric  resonance,  the  coin  sound,  etc.,  may  be  present  in  abscesses 
containing  air.  The  apex  beat  of  the  heart  may  be  displaced  up- 
ward, but  seldom  laterally. 

6.  Localizing  Signs  should  be  looked  for  as  an  aid  to  operation. 
They  embrace  bulging;  tenderness;  increase  in  circumference  of  the 
lower  thorax  on  the  side  affected ;  oedema ;  enlargement  of  the  veins, 
etc.     The  Roentgen  rays  should  be  used  if  possible. 

7.  Aspiration  is  dangerous  unless  followed  by  immediate  operation 
when  pus  is  found;  on  the  other  hand,  failure  to  find  pus  by  no  means 
excludes  the  presence  of  an  abscess,  but  may  cause  the  postponement 
of  an  operation  until  it  can  no  longer  be  of  benefit.  Hence  the  needle 
should  not  be  used  until  the  patient  is  on  the  operating  table  ready  for 
any  operation  that  may  seem  proper. 

Prognosis. — The  prognosis  of  subphrenic  abscess  is  bad,  no 
matter  what  the  treatment ;  but  it  is  very  much  worse  if  no  operation 
is  done,  or  if  operative  treatment  is  too  long  delayed.  Among  Bar- 
nard's cases  there  were  64  patients  treated  by  73  operations;  of  this 
number  40  patients  recovered,  and  24  died,  a  general  mortality  of 
37.5  per  cent.  Death  resulted  in  every  patient  not  operated  upon. 
Among  the  44  cases  of  suppuration  in  the  lesser  peritoneal  cavity 
collected  by  Michel  and  Gross,  there  were  19  patients  treated  by 
operation ;  all  those  not  operated  upon  died,  while  of  the  others  only 
9  died,  a  death  rate  of  47.36  per  cent.  Of  the  patients  with  subphrenic 
abscess  following  appendicitis,  studied  by  Eisendrath,  84  were 
treated  by  operation,  with  23  deaths,  a  mortality  of  27.38  per  cent.; 
while  the  death  rate  among  patients  not  operated  upon  was  over  82 
per  cent. 

Barnard  concludes  that,  speaking  in  a  general  manner,  posterior 
29 


450  Complications  and  Sequels. 

methods  of  drainage  give  more  favourable  results  than  do  the  ante- 
rior. In  his  series  of  cases,  26  posterior  operations  were  performed, 
with  7  deaths  (27  per  cent.);  43  anterior  operations,  with  17  deaths 
{39.5  per  cent.);  and  4  lateral,  witli  3  deaths  (75  per  cent.).  He  has 
himself  performed  24  operations  on  21  patients  for  subphrenic  ab- 
scess; 15  of  these  operations  were  posterior,  with  2  deaths  (13.3  per 
cent.);   and  9  were  anterior,  with  2  deaths  (22.2  per  cent.). 

Treatment. — The  operations  for  subphrenic  abscess  may  be 
classed  in  accordance  with  Barnard's  tables,  as  anterior,  posterior, 
and  lateral.  The  former  include  abdominal  incisions,  whether  in  the 
epigastrium  or  in  one  of  the  hypochondriac  regions.  The  posterior 
operations  include  the  subpleural  and  transpleural  approaches  through 
the  diaphragm;  they  resemble  the  usual  operations  for  hepatic  abscess, 
which  will  be  described  in  connection  with  that  lesion  in  Volume  II. 
Lateral  transpleural  or  subpleural  operations  should  not  be  attempted 
unless  the  abscess  is  very  manifestly  pointing  in  the  axillary  line. 

When  the  existence  of  subphrenic  abscess  is  suspected,  it  is  some- 
times better,  as  pointed  out  by  Barnard,  to  delay  operation  for  three 
or  four  days  in  order  to  allow  the  abscess  to  become  more  accessible. 
This  applies  particularly  to  infections  beneath  the  right  dome  of  the 
diaphragm,  secondary  to  disease  of  the  liver.  When  the  abscess  is 
believed  to  be  in  other  situations  we  believe  delay  to  be  dangerous,  and 
think  an  exploratory  laparotomy  should  be  undertaken  as  soon  as  the 
presence  of  pus  is  reasonably  certain,  even  though  its  exact  location 
cannot  be  pre-determined.  By  opening  the  peritoneal  cavity  and 
cautiously  disposing  gauze  packs  before  attempting  any  exjjloration 
whatever,  or  before  rupturing  any  adhesions,  it  usually  will  be 
possible  to  discover  the  situation  of  the  abscess,  and  then  to  ap- 
proach it  b\'  the  thoracic  or  lumbar  route  should  sucli  a  course  l)e  ad- 
visable. Especially  dangerous  is  delay  in  those  subphrenic  or  peri- 
gastric abscc.s.ses  which  arise  as  the  localized  remains  of  a  diffuse 
peritonitis  (residual  ab.scesses).  In  such  cases  tlie  h'niiting  adhesions 
are  never  so  firm  as  in  subacute  or  chronic  ])erforations,  and  unless 
the  abscess  be  evacuaterj  so  soon  as  its  j)resence  is  detected,  it  will  be 
sure  to  break  again  and  produce  sjjreading  librino-purulent  j)eri- 
tonitis. 


Subphrenic  Abscess.  451 

The  use  of  the  exploring  needle  may  be  preferred  to  laparotomy 
when  the  patient,  prepared  for  operation,  is  on  the  operating  table, 
and  the  surgeon  has  good  reason  to  believe  that  the  abscess  is  beneath 
the  costal  margin.  Attention  to  the  known  pathogenesis  of  sub- 
phrenic abscess  will  frequently  enable  this  point  to  be  ascertained 
with  reasonable  certainty. 

In  all  cases  in  which  the  abscess  has  to  be  approached  by  the  an- 
terior (abdominal)  route  it  will  be  much  safer  for  the  surgeon  to  open 
it  transperitoneally  after  thoroughly  protecting  all  surrounding  struc- 
tures by  gauze  packs,  than  for  him  to  attempt  to  cut  directly  into  the 
abscess  cavity.  In  the  latter  method  of  operating  the  surgeon  can 
never  be  entirely  sure  that  his  incision  itself  has  not  trespassed  beyond 
the  limiting  adhesions,  nor  that  his  manipulations  have  not  produced 
leakage  into  the  general  peritoneal  cavity  at  some  other  point  of  the 
abscess's  periphery. 

For  anterior  perigastric  abscess,  median  or  left  hypochondriac 
laparotomy  is  to  be  preferred.  Drainage  may  be  provided  for  by  a 
counter  opening  in  the  left  flank,  if  the  abscess  extends  far  toward 
the  spleen. 

For  posterior  perigastric  abscess  (suppuration  in  the  lesser  cavity 
of  the  peritoneum),  laparotomy  should  be  done,  and  the  abscess  opened 
where  most  prominent — whether  it  points  through  the  gastro-hepatic 
or  through  the  gastro-colic  omentum,  or  through  the  transverse  meso- 
colon. Though  recovery  has  followed  anterior  drainage  alone,  it  is 
much  safer  to  make  a  counter  opening  in  the  left  loin,  below  the  last 
rib;  under  such  circumstances  it  is  occasionally  proper  to  close  the 
anterior  incision  without  drainage.  If  the  location  of  the  abscess  in 
the  lesser  peritoneal  cavity  has  been  determined  before  operation,  an 
attempt  should  be  made  to  open  it  through  the  left  ilio-costal  space. 
This  route  has  been  employed  twice  successfully  by  Dr.  Deaver,  once 
as  the  primary  operation,  and  once  after  locating  the  abscess  by 
laparotomy. 

For  a  subphrenic  abscess  which  involves  the  siihhepatic  space 
and  right  renal  pouch,  laparotomy  combined  with  counter-drainage 
in  the  right  loin  should  be  employed. 

When  the  abscess  does  not  extend  beyond  the  confines  of  the  costal 


452  Complications  and  Sequels. 

margin  on  the  right  it  is  sufficient  to  drain   it  by  the  thoracic  in- 
cision. 

The  thoracic  operation  should  never  be  employed  if  there  be  diffuse 
peritonitis.  In  the  presence  of  this  additional  complication  there  is  a 
choice  of  two  methods  of  procedure:  i.  If  it  appear  that  the  patient 
will  survive  the  immediate  shock  of  an  operation,  laparotomy  should 
be  done,  the  cause  of  the  peritonitis  abated,  and  drainage  of  the 
pelvis  provided  for,  as  well  as  of  the  side  of  the  subphrenic  space  in- 
volved. 2.  If  the  peritonitis  has  advanced  so  far  that  no  operation 
can  be  undertaken  without  great  probability  of  hastening  the  patient's 
death,  the  starvation  treatment  of  Ochsner  should  be  adopted;  but 
any  localized  collection  of  pus  must  be  opened  as  soon  as  it  is  dis- 
covered— delay  of  even  twelve  hours  may  place  the  patient  beyond  the 
reach  of  surgery.  Whichever  plan  of  treatment  be  adopted,  the  head 
of  the  patient's  bed  should  be  raised  30  degress  from  the  floor  (Fowler's 
position),  to  aid  the  gravitation  of  septic  fluids  to  the  pelvis.  Saline 
solution  should  be  constantly  administered  by  the  bowel. 

REFERENCES. 

Ashhurst,  Astley:  Amer.  Jour.  Med.  Sc,  1902,  cxxiv,  629. 

Barnard:  Brit.  Med.  Jour.,  1908,  i,  371;  429. 

Bouchard:   Cited  by  Eisendrath,  loc.  infra  cit. 

Eisendrath:  Jour.  Amer  Med.  Assoc,  1908,  i,  751. 

Elsberg:  Annals  of  Surgery,  1901,  xxxiv,  729. 

Finkelstein:   Centralbl.  f.  Chir.,  1899,  xxvi,  250. 

Freeman:   Keen's  Surgery,  Phila.,  1906,  Vol.  I,  p.  268. 

Maydl:   "Ueber  subphrenische  Abscesse,"  Wien,  J.  Sofar,  1894. 

Michel  and  Gross:   Revue  de  Gyn.  et  de  Chir.  Abd.,  1904,  viii,  45. 


INDEX  OF  NAMES. 


Abel,  140 

Aborg,  Key,  326,  329 

Abt,  140 

Adami,  45 

Albers,  229 

Albu,  209 

Alessandri,  239 

Alloncle,  201 

Amyand,  186 

Anderson,  123,  229,  331 

Andral,  234 

Arnsperger,  257 

Ashby, 134 

Ashhurst,  John,  Jr.,  183,  232,  335 

Auvray,  324 


Bainbridge,  268 

Baldauf,  209 

Barbera,  245 

Barchasch,  238 

Bard,  216 

Bardeleben,  192,  335,  386 

Bardenheuer,  263 

Barker,  210 

Barling,  140 

Barlow,  443 

Barnard,  443,  448 

Barton,  228 

Battle,  266 

Baudouin,  180 

Baylac,  245,  247 

Bazy,  210,  211 

Beardsley,  133,  223 

Beaumont,  31 

Benaky,  226 

Benjamin,  335 

Bennett,  221,  224,  388 

Benoit,  315 

Berard,  216 

Bereznegovsky,  243 

Berg,  207,  253,  286,  293,  441 

Bergmann,  183,  195,  217,  304 

Bernays,  334 

Bernoulli,  269 

Berry,  314 

Beyea,  177,  389 

Bid  well,  86,  117 

Bier,  188,  223 


453 


Billot,  336 

Billroth,  116,  183,  299,  334,  391,  437 

Bircher,  176,  214,  218,  358,  388 

Bird,  245,  247 

Blake,  192 

Blanc,  433 

Bland  Sutton,  286 

Bloch,  139 

Boas,  278,  282,  292 

Bochlendorf,  228 

Bonheim,  123,  128 

Boothby,  28 

Borchardt,  253 

Borden,  320 

Borel,  249 

Borrmann,  214,  275 

Bottomley,  140 

Bouchard,  443 

Bouveret,  214 

Bovee,  251 

Brauer,  405 

Braun,  125,  140,  286,  290,  296,  368, 

420 
Brechot,  116,  118 
Brinton,  73,  100,  234,  274 
Brissaud,  234,  236 
Broca,  180 
Brunner,  C,  112 
Brunner,  F,  122,  125,  202,  204 
Brush,  327 
Bryant,  268 

Biidinger,  192,  195,  318 
Bull,  140 
Bullitt,  120 
Bulstrode,  104 
Bunts,  140,  141 
Burghard,  140 
Buxton,  54 

Cackovic,  337,  338,  441 
Cahen,  318 
Caird,  123 
Cameron,  103 
Caminiti,  214 
Campbell,  140 
Cannon,  51 
Cappello,  214,  306 
Carle,  13,  103,  107,  187 


454 


Index  of  Names. 


Carrion,  14S 

Castellvi  y  Pallares,  228 

Catani,  1S3 

Cautley,  133 

Cazin,  121 

Cernezzi,  214,  215 

Chamayou,  245,  247 

Chaput,  221,  224,  333,  421 

Chauffard,  70 

Chavannaz,  437,  439 

Cheney,  140 

Chenieux,  335 

Chevalier,  334 

Chevassu,  243 

Chevrier,  238,  240,  366 

Chiari,  245,  327 

Childe,  2Q7 

Chlumskij,  421 

Christian,  iSg,  210 

Chutro,  Pedro,  228,  330 

Chvostek,  201,  203 

Clairmont,  119 

Cleemann,  209 

Clement,  194 

Cloquet,  230 

Codivilla,  207 

Cohn,  214,  226 

Collin,  201,  202 

Collum,  209 

Colmers,  290 

Connell,  432 

Conner,  147 

Corner,  306 

Creite,  292,  298 

Crile,  105,  281,  286 

Cruvcilhier,  186,  226 

Cuneo,  13,  274,  394 

Cunningham,  171 

Curschmann,  238 

Cushing,  42 

Cutler,  214 

Czerny,  105,  188,  286,  308,  438 


Dandois,  336 
Dastre,  421 
Dawson,  296 
Dean,  207 
Deitz,  259 
Delamare,  186 
Dclbet,  236 
Delporte,  336 
T)fmarr|uay,  89 
Dcmoulin,  117,  179 
D<'n((hau,  loS 
Dennis,  265,  266 
Dent,  133,  140 
Devic,  216 


Dickinson,  54 
Dieulafe,  186 

Dieulafoy,  70  120,  200 

Dobson,  13,  275 

Docq,  241 

Doderlein,  277 

Domenici,  42 

Doyen,  188,  192,  369,  421 

Dubois,  335 

Dufour,  140 

Dujarier,  228 

Dujon,  253,  254 

Dunn,  207 

Dupraz,  230 

Durante,  238,  242,  366 

Duret,  177,  388 

Durk,  238 

Duvernoy,  230 


Edington,  433 

Edmunds,  335,  336,  438 

Edsall,  103 

Ehrenberg,  214,  218 

Einhorn,  245 

Eiselsberg,  116,   117,   120,   123,   173,   190, 

218,  384,  438 
Eisendrath,  448 
Elsberg,  447 
Elting,  140 
Emerson,  209 
Engelbcrt,  353 
Engelhorn,  277 
Engel-Reimers,  230 
English,  122,  127,  129 


Erdman, 
Eriach,  215,  218 
Ewald,  307 
Ewing,  272 


Fagge,  Hilton,  147 

P'airbank,  306 

P'antino,  103,  107 

I-'enwick,  22  [,  226,  246,  269,  303,  304,  307 

Feroualle,  129 

Ferrari,  242 

Fink,  441 

p'inkelstein,  443,  446 

Finnel,  229 

Finney,  113,  122,  154,  210,  230,  362 

iMscher,  226,  298,  438 

Fisk,  137,  139,  141 

Fleincr,  172 

Flexncr,  245 

de  l'"ont-Reaulx,  262 

Fofjte,  194 


Index  of  Names. 


455 


Forgue,  319,  321,  325 
Fowler,  369,  419,  421 
Fox,  269 

Fraenkel,  326,  329 
Frank,  357 
Frattini,  183 
Fredet,  140 
Freeman,  267,  443 
Fray,  262 
Friedrich,  336 
Fritsche,  140 
Fuchsig,  318 


Gage,  338 

Gallavardin,  216 

Gallet,  298 

Gallois,  229,  331 

Gandy,  70,  200 

Gardiner,  186 

Gardner,  136,  139 

Garre,  287,  439 

Gask,  106 

Gaston,  373 

Geill,  328 

Genrich,  201 

Gersuny,  187 

Gibbon,  123,  128,  312 

Gilbert,  42 

Giles,  140 

Gillavry,  140 

Gilly,  232 

Giorgi,  240 

Giuliani,  217 

Glaser,  258 

Glaubitt,  238 

Glenard,  45,  174 

Gluck,  359 

Glucksmann,  207 

Godineau,  336 

Gordon,  266 

Gosset,  431,  434,  440 

Gottstein,  183 

Gould,  206,  354,  374 

Goullioud,  214,  216,  218,  ; 

Gourrand,  223 

Graf,  413 

Gramse,  360 

Granborn,  140 

Grassberger,  198 

Greenough,  103 

Grenier  de  Cardenal,  259 

Grisson,  140 

Gross,  122,  129,  441,  446 

Grosser,  259 

Grossman,  234 

Griinfeld,  201 

Grunneberg,  140 


187 


Guibal,  313 
Guillemot,  187 
Guinard,  299 
Gumprecht,  172 
Guthrie,  140,  26^ 


Haberda,  326 

Hacker,  187,  194,  368,  421 

Hadra,  420 

Hagen,  330 

Hahn,  113,  195,  230,  287,  314,  439 

Hallon,  148 

Halsted,  305 

Hammer,  177 

Hanau-Albrecht,  148 

Hansemann,  198 

Harte,  91,  337,  435 

Hartley,  140 

Hartmann,  105,  106,  121,  177,  188,  226, 

287,  296,  345,  371,  377,  394 
Harvie,  336 
Hattute,  238 

Hayem,  221,  245,  247,  270,  271 
Hebb,  229 
Hedlund,  195 
Helferich,  105,  218,  413 
Hemmeter,  143 
Henle,  186 
Henschel,  134,  438 
Hentschel,  298 
Herczel,  242,  338 
Herhold,  218 
Herzen,  360 
Heubel,  198 
Heubner,  136 
Hildebrand,  250,  330 
Hilgenreiner,  121,  188,  198,  276,  441, 

436 
Hinds,  224 
Hinton,  441 
Hirsch,  198 
Hobson,  209 
Hochenegg,  105 
Hodge,  325 
Hoffmann,  283,  327 
Holding,  336 
Hollscher,  211 
Holstein,  230 
Home,  186 
Hontang,  229,  331 
Hoover,  245 
Horrocks,  198 
Hort,  71 
Hosch,  303,  304 
Humbert,  314 
Hunter,  68 
Hutchinson,  229 


456 


Index  of  Names. 


Ibrahim,  140 
Ilderton,  336 
Ipsen,  327 
Iselin,  263,  311,  313 


Jaboulay,  26,  230,  368,  420 

Jacobi,  286 

Jacobson,  335 

Jaffe,  123,  259 

Jakh,  140 

Jamieson,  13,  275 

Jaworski,  191 

Jean,  214 

Jeanbrau,  319,  321,  325 

Jeannel,  338 

Jedlicka,  116,  117,  192,  270,  405 

Jones,  Sidney,  70,  206 

Jonnesco,  173,  234,  384 

Jordan, 140 

Joslin,  103 

Jullien,  245 

Juvara,  336 


Kader,  356 

Kammerer,  90,  177,  192,  387 

Kappeler,  287 

Karewski,  407 

Katzenstein,  103 

Kauffman,  439 

Kaupe,  121 

Kausch,  107,  186,  289,  292,  303,  431 

Kehr,  140,  441 

Kelling,  49,  148,  175,  281,  415,  421,  439 

Kelly,  266,  278 

Kemke,  215,  216 

Key,  431 

Khautz,  123 

Kidd,  214 

Kimball,  140 

Kirchner,  318 

Kirk,  123,  129 

Kirsch,  245 

Klebs,  277 

Klein,  186,  187 

Kleine,  198 

Klemperer,  49 

KJose,  243 

Knaggs,  314 

Kocher,  107,  281,  284,  287,  291,  298, 

299.  3^>o.  367,  393 
Kolarzek,  198,  214 
Konig,  314 

Korte,  129,  187,  195,  330,  332 
Krannhals,  201 
Kraskc,  441 


Krause,  105,  195,  293,  298 

Krecke,  415 

Krogius,  116 

Kronlein,  287,  292,  293,  294,  431 

Krukenberg,  192,  386 

Kuliga,  209 

Kiimmel,  123,  195 

Kundrat,  98 

Kurt,  234 

Kussmaul,  145 

Kiister,  188 


Labhardt,  438 

Laboulbene,  215 

Lacher,  260 

Ladeveze,  211 

Laffer,  147,  148,  153 

Lafleur,  245,  247 

Lambotte,  360 

Landerer,  207 

Lange,  224 

Langenbuch,  187 

Langerhans,  188,  253 

Lantschner,  327 

Laroyenne,  218 

Laspeyres,  203 

Lauenstein,  336,  368,  420 

Lebert,  100 

Lecene,  305 

Ledderhose,  183 

Le  Dentu,  335 

Leersum,  236 

Le  Fillier,  335 

Leflaive,  229,  331 

Leisrink,  314 

Leith,  249,  251 

Lejars,  336 

Le  Mee,  180 

Lengemann,  275 

Lennander,  251,  415 

Lenormant,  262,  311 

Lenzmann,  245 

Leriche,  239,  280,  290,  291,  300,  367, 

404,  436 
Letulle,  211 

Lieblein,  121,  18S,  19S,  276,  436,  441 
Lilienthal,  441 
Littlcwood,  123,  420 
Lobker,  133,  140 
Louis,  238 
Lowry,  336 
Lucas,  S33 
Lucke,  369 
Luton,  273 
Lyman,  224 
Lyng,  316,  318 


Index  of  Names. 


457 


McCORMICK,  298,  305 

McCosh,  92,  222 

McGraw,  373 

Mackay,  140 

McKendrick,  167,  171 

Mackenzie,  86,  210,  211,  266 

McLaren,  217 

McLean,  374 

McLeod,  336 

McRae,  266 

Magnus-Alsleben,  214 

Maiocchi,  318 

Makkas,  290,  292 

Margarucci,  242 

Martin,  184,  314,  321,  323 

Massman,  298 

Mattoli,  243 

Mauclaire,  325,  439 

Mauler,  221 

Maydl,  116,  287,  296,  407,  443 

Mayer,  230 

May  lard,  134,  308 

Mayo,  C.  H.,  374 

Mayo,  W.  J.,  31,  54,  105,  106,  113,  128, 

184,  200,  203,  270,  287,  307,  374,  381, 

401, 420,  441 
Mazzotti,  253 
Meerwein,  329,  338,  339 
Meltzer,  138 
Menetrier,  223,  271,  307 
Menne,  331 
Mesnard,  129 
Meyer,  140,  287 
Michel,  446 
Mikulicz,   113,   122,    140,   183,   194,  251, 

287,    292,    294,    303,    330,    332,    415, 

447 
Millard,  70 
Miller,  103 
Mintz,  103,  107 
Miodowski,  214,  215 
Mitchell,  123,  124 
Mixter,  267 
Mollard,  216 
Mongour,  44 
Monnier,  140,  336 
Monprofit,  195,  287,  293 
Monro,  214,  217 
Morgagni,  186,  211 
Morgan,  245,  246 
Morison,  105,  114,  140 
Morone,  236 
Moser,  214,  218 
Mosetig-Moorhof,  199 
Mosse,  431 

Moullin,  70,  77,  162,  235 
Moynihan,  3,  91,  105,  106,  120,  121,  128, 

186,    igo,   195,  205,  224,  249,  270,   287, 


289,  292,  294,  29s,  298,  339,  370,    38 r, 

388,  420,  431 
M  tiller,  121,  149 
Mumford,  loi,  104,  270,  274 
Munro,  121,  140,  379 
Murdock,  102 
Murphy,  140,  374,  375,  382 
Murray,  226 


Naumann,  263 
Nauwerck,  70 
Neck,  147 
Neelsen,  214 
Neilson,  447 
Neumann,  330  ■ 
Neurath,  133 
Newman,  327 
Nichols,  217 
Nicoladoni,  192,  219, 
Nicoil,  140,  367 
Niemeyer,  215 
Nisbet,  100,  159,  170 
Noll,  214 
Norman,  223 
Nowak,  205 
Nussbaum,  335 


Oberst,  305 

Ochsner,  28,  50,  210,  219,  374 

Odier,  272 

Qitinger,  236 

Opie,  45  _ 

Oppenheimer,  201,  202 

Orth,  98,  226,  326 

Osier,  133 


Page,  250 

Pagenstecher,  207 

Pancoast,  176 

Pantzer,  117 

Papellier,  70 

Parrot,  216 

Patel,  266,  436 

Paterson,  102,  103,  109, 122,  127,  193,  194, 

287,  289,  291,  293,  299,  420 
Paus,  282 
Pean,  391 
Peck,  123 
Pendl,  253 
Perls,  214 
Permann,  263 
Perry,  202,  303,  307,  339 
Petersen,  243,  290,  369,  382,  420 


458 


Index  of  Names. 


Petit,  305 
Petn-,  327,  329 
Pfahler,  64,  176 
Pfaundler,  136 
Picenti,  215 
Pilcher,  211 
Pilliet,  236 
Pinatelle,  126,  127 
Pinner,  140 
Pitt,  232 
Plummer,  184 
Poirier,  214,  219 
Poisson,  70 
Poncet,  239 
Poppert,  287 
Postempski,  263 
Power,  D'Arcy,  105 
Preble,  97 
Preindlberger,  318 
Proskauer,  70 
Putnam,  iSo 


QUAIN,  223 
Quenu,  121,  431 


Ramsay,  337 

Rasmussen,  70,  187 

Read,  229 

Regnier,  153 

Rehn,  123,  318,  328,  332 

Reichel,  298,  438 

Rendu,  229,  230,  331 

Revenstorf,  335,  336 

Revilliod,  327 

Rhein,  257 

Ricard,  238,  240,  366 

Richardson,  26 

Riche,  296 

Riegcl,  211 

Riegncr,  265 

Riese,  287 

Riesman,  24 

Rintel,  441 

Roberts,  J.  B,  72 

Robertson,  140,  249 

Robineau,  179 

Robinson,  154 

Robson,  Mayo,  3,  91,  105,  106,  117,   121, 

185,  188,  205,  208,  224,  242,  249,   287, 

291,  295,  416,  431 
Rockwitz,  368 
Rodman,  116,  118 
Rogers,  140 
Rolleston,  25,  308 
Ropke,  269 


Rosenheim,  1S3 

Ross,  298 

Rotgans,  105 

Routier,  147 

Roux,  116,  181,  207,  236,  287,  35S,  368, 

Rovsing,  177 
Riige,  243 
Rupprecht,  219 
Russdorf,  226 
Russell,  183 
Ruyschius,  228 
Rydygier,  116,  264,  391 


Saake,  253 

Sailer,  176,  257 

Samter,  214,  219 

Sappey,  32 

Sauerbruch,  iSi,  405,  406 

Savariaud,  73,  121 

Sauve,  297 

Schede,  441 

Schloffer,  105,  192,  293 

Schmaler,  245 

Schmidt,  Meinhard,  133,  140,  1S6,  330 

Schnarrwyler,  249 

Schnitzler,  186,  195 

Schoenborn,  287 

Schomerus,  187,  193 

Schostak,  432 

Schotten,  140 

Schou, 105 

Schiiller,  307,  308 

Schulten,  198 

Schultz,  152 

Schwabe,  Daniel,  334 

Schwartz,  247 

Schwyzer,  133 

Scudder,  128,  140 

Sedillot,  353 

Seelig,  149 

Sencert,  353,  406 

Senn,  E.  J.,  355 

Serege,  45 

Shaw,  202,  209,  303,  307,  Tf^i) 

Sheldon,  235 

Sherwood,  338 

Shield,  5 

Siege!,  315,  318 

Siibermark,  19S 

Silvestri,  43 

Simmonds,  23S 

Sklifossowsky,  221 

Sloane,  229,  331 

Smith,  123 

Socin,  368 

Sonncnhurg,  123 


Index  of  Names. 


459 


Sorrentino,  311 

Soupault,  103,  107 

Ssapesko,  118 

Ssbanajew,  357 

Stamm,  355 

Stavely,  210 

Steaton,  441 

Steel,  179 

Steiner,  214 

Stern,  133,  140 

Steudel,  107,  421 

Stevens,  222 

Stewart,  123,  209,  311 

Stiles,  140,  393 

Still,  137 

Stockis,  232 

Stone,  loi,  104,  140,  270 

Strassmann,  70,  269,  326,  328 

Summers,  176,  337 

Surmay,  407 

Suter,  310,  311,  314 

Sutton,  J.  Bland,  286 

Syme,  308 

Tansini,  236 

Tarnier,  179 

Tavel,  357 

Tawastsjerna,  329 

Taylor,  W.  J.,  24,  97 

Terrier,  117,  153,  367,  419 

Thommen,  330,  332 

Thompson,  327 

Thorburn,  336 

Thorel,  198 

Tichoff,  243 

Tilanus,  334 

Tilger,  198,  214,  226 

Torrey,  54 

Trautenroth,  133,  140 

Trier,  201 

Trump,  209 

Tuffier,  117,  121,  228,  245,  315,  32 

Tvson,  286 


Ulmann,  357 
Ungar,  326 
Unruh,  439 


Vallas,  230 

Van  Valzah,  100,  159,  170 

Vassalo,  287,  403 


Vatter,  332 
Veillard,  180 
Verhoogen,  242" 
Villard,  126,  127 
Villemin,  180,  313 
Virchow,  226 
Volkmarin,  443 
Voswinckel,  330 


Wachenheim,  133 

Wagner,  441 

Walker,  313 

Wallis,  117 

Warbasse,  335,  336 

Warren,  260 

Watson,  193 

Weber,  C.  H.  149 

Webster,  232 

Weir,  194,  202,  206 

Welch,  269 

Welsh,  298,  305 

Wendel,  405 

Werder,  336 

Wernstedt,  136 

White,  104,  123,  277 

Whiting,  119,  266 

Widermann,  257 

Wideroe,  281 

Wiener,  406 

Wiesinger,  253 

Wilke,  253,  327 

Winands,  230 

Witte,  281 

Witzel,  354 

Wolfler,  186,  368,  387,  421 

Tir 1     T^A 


Wood,  126 
Worden,  168,  175' 
Wrigley,  318 
Wullstein,  359 
Wunscheim,  326 


Yates,  214,  303,  304,  305 
Young,  126 


Zade,  148,  154 
Zahn, 198 

Zeigler,  228,  230,  331 
Zeller,  195 
Zirkelbach,  281 
Zweig,  439 


NDEX 


Abdomen,  anatomy,  surface,  3 

preparation  for  operation,  342 
Abdominal  wall,  anatomy  of,  i 

cutaneous  hyperaesthesia,  2 
muscular  rigidity,  2 
Abscess,  perigastric,  85 

stomach,  330 

subphrenic,  85,  443 
Adenoma,  stomach,  221 
operations,  224 
Alimentary  tract,  movements,  46 
Ampulla  of  Vater,  22 
Amylopsin,  38 

Anaemia  in  ulcer  of  stomach,  79 
Anaesthetic,  342 
Anamnesis,  56 
Anatomy,  abdomen,  surface,  3 

abdominal  wall,  i 
Angeioma,  stomach,  232 
Angeio-sarcoma  stomach,  217 
Appetite,  53  _ 
"Appetite-juice,"  35 
Artery,  coronary,  12 

gastric,  12 

gastro-epiploica  dextra,  12 

gastro-epiploica  sinistra,  12 

hepatic,  22 

mammar\%  internal,  2 

pyloric,  12 
Atrium  bursse  omentalis,  20 
Auscultation,  59 


Bacteria,  duodenal,  42 

gastric,  42 

intestinal,  42 

action  of,  41 
Bile,  action  of,  39 

secretion,  38 
Brunner's  glands,  32 


C^co-coLic  sphincter,  50 
Cancer.     Vide  Carcinoma. 
"  Cancerogene,"  273 
Caput  MeduscC,  24 
Carcinoma,  duodenum,  30; 
stomach,  268 

aetiology,  268 


Carcinoma,  stomach,  diagnosis,  282 
by  .T-ray,  64 

duodenostomy,  296,  300 

gastrectomy,  286 
cylindrical,  300 
partial,  299 
subtotal,  297 
total,  297 

gastro-jejunostomy,  293 

gastrostomy,  296,  300 

Glutzinsky's  test,  281 

haemolytic  blood  test,  281 

histology,  271 

jejunostomy,  296,  300 

metastasis,  274 

prognosis,  285 

resection,  300 

Salomon's  test,  281 

symptoms,  278 

treatment,  297 
Cardia,  obstruction  of,  185 

resection,  405 
Cardiospasm,  183 
Central  tendon  of  diaphragm,  4 
Cholecysto-duodenal  fistula,  442 
Circulus  vitiosus,  419 
Cirrhosis  of  stomach,  234 
Common  duct,  21 
Concretions  of  stomach,  232 
Coronarj'  arterj-,  12 
Cyst  of  stomach,  228,  330 

degeneration,  229 

dermoid,  228 

gaseous,  230 

hydatid,  228 

lymphangeiomatous,  229 

operation,  230 

retention,  228 

traumatic,  228 
Cystic  duct,  20 
Cystico-coKc  ligament,  20 


"Deadly  angle,"  393 

Death  after  operation,  causes  of,  411 

Deglutition,  47 

Diagnosis,  auscultation,  59 
gastric  analysis,  60 
general  considerations,  56 


461 


462 


Index. 


Diagnosis,  inspection,  57 
mensuration,  60 
palpation,  57 
percussion,  58 
skiagraphy,  62 
x-ra}',  62 
Diaphragm,  central  tendon,  4 
eventration,  257 
injuries,  310 
rupture,  313 
wound,  gunshot,  313 
operative,  314 
stab,  310 

operations,  312 
Diaphragmatic  hernia,  259 
Digestion,  32 
gastric,  35 
intestinal,  37 
physiology,  31 
prephase,  34 
salivary,  35 
Dilatation,  duodenum,  210 
stomach,  acute,  147 

diagnosis,  152 
operations,  155 
patholog)',  149 
prognosis,  153 
symptoms,  151 
treatment,  153 
atonic,  157 

treatment,  159 
secondar}',  161 

diagnosis,  168 
pathology,  163 
pirognosis,  171 
sym])toms,  165 
treatment,  172 
Diverticula,  duodenum,  211 

stomach,  186,  198 
Duct,  common,  21 
cystic,  20 
hepatic,  2r 
Duodenal  fistula,  441 
Duodeno-colic  fistula,  442 
Duodenof)lasty,  210 
Duodenostomy,  120,  408 

carcinoma  of  stomach,  296,  300 
Duodenum,  bacteria,  42 
benign  diseases,  67 
f  arrinoma,  307 
flilatation,  210 
diverticula,  2J  r 
emljryology,  6 
foreign  body,  ;^^^j^ 
hour-glass,  210 
impcrforalion,  209 
injuries.  337 
nco[)lasm,  benign,  213 


Duodenum,  position  of,  4 

rupture,  338 

sarcoma,  308 

sphincter,  28 

stenosis,  209 

stricture,  209 

congenital,  209 

topographical  anatomy,  26 

ulcer,  200 

"hunger  pain,"  203 
operations,  206 
perforation,  203 
prognosis,  205 
s_ymptoms,  202 
treatment,  206 

wound,  gunshot,  337 
stab,  337 


"Embaras  gastrique,"  145 
Embrj'ology,  6 
Endogastritis  obliterans,  234 
Entero-anastomosis,  381 
Enterokinase,  40 
Erepsin,  40 

Eventration  of  diaphragm,  257 
Excision  of  stomach,  391 
Exclusion  of  pylorus,  173,  384 


FvECES,  composition,  43 

Fibroma,  stomach,  214 

Fistula,  cholecysto-duodenal,  442 
duodenal,  441 
duodcno-colic,  442 
gastric,  external,  436 

internal,  437 
gastro-colic,  437 
gastro-cutaneous,  436 
gastro-duodenal,  442 
jejuno-colic,  440 
post-operative,  436 

Food-stuffs,  33 

Foreign  body  in  duodenum,  ;^^^ 
stomach,  332 


Gall-bladder,  position,  4,  18 
Gastrectasis,  146 
Gastrectomy,  390 
circular,  390 
cylindrical,  391,  403 

for  carcinoma,  300 
for  hour-glass  sloinach,  i(>5 
partial,  390 

Billroth's  second,  396 
for  carcinoma,  286,  299 
Kochcr's,  393 


Index. 


463 


Gastrectomy,  subtotal,  390,  401 
for  carcinoma,  297 

total,  390 

for  carcinoma,  247 
Gastric  artery,  12 

digestion,  35 

dilatation,  146     {Vide  stomach,  dila- 
tation). 

fistulae,  436 

juice,  analysis  of,  60 

myasthenia,      157     (Vide     stomach, 
dilatation,  atonic). 

resection,  391,  404 

tetany,  166,  171 

ulcer,  67     (Vide  ulcer  of  stomach). 
Gastritis,  phlegmonous,  249 

submucous,  249 
Gastro-anastomosis,  192,  387 
Gastro-colic  fistula,  437 
Gastro-cutaneous  fistula,  436 
Gastro-duodenal  fistula,  442 

reflex,  422 
Gastro-duodenostomy,  Kocher's,  367 
Gastro-enterostomy,  112 
Gastro-epiploic  artery,  rupture,  331 

stab  wound,  318 
Gastro-epiploica  dextra  artery,  12 

sinistra  artery,  12 
Gastro-gastrostomy,  193,  387 
Gastro-jejunostomy,  115,  194,  368 

anterior,  371 

for  carcinoma,  293 

hernia  following,  435 

McGraw  ligature,  374 

posterior,  in  -Y,  383 
long-loop,  375 
no  loop,  381 
Gastrolysis,  115 
Gastropexy,  388 

Beyea's,  389 

Buret's,  388 
Gastroplasty,  192,  386 
Gastroplication,  176,  388 
Gastroptosis,  65,  174 

symptoms,  175 

treatment,  176 
Gastrostomy,  353 

for  carcinoma,  296,  300 

Herzen's,  360 

Kader's,  356 

Roux's,  358 

Senn's,  355 

Ssbanajew-Frank,  357 

Tavel's,  357 

Witzel's,  354 
Gastrotomy,  351 

for  foreign  body,  334 
Globus  hystericus,  167 


Glutzinsky's  test,  281 

Glycogen,  41 

Glycosuria,  alimentary,  41 

Great  omentum,  developement,  12 

Gumma  of  stomach,  245 

Gunshot  wound,  diaphragm,  313 

duodenum,  337 

stomach,  319 


H.a;MATEMESis,  ulcer,  stomach,  78 
Haematoma,  stomach,  330 
Hemorrhage  in  ulcer,  stomach,  80 
Hepatic  arter}%  22 

duct,  21 
Hernia,  diaphragmatic,  259 

operations,  266 
internal,  435 
Hour-glass  duodenum,  210 
stomach,  186 

congenital,  186 

digital  divulsion,  191 

gastrectomy,  195 

gastro-gastrostomy,  193 

gastro-jejunostomy,  194 

gastroplasty,  192 

Jaworski's  sign,  191 

operations,  196 

pathology,  187 

symptoms,  190 

treatment,  191 

volvulus,  188 

Wolfler's  sign,  191 
Hyperacidity  in  ulcer,  stomach,  79 
Hyperaesthesia,  cutaneous,  2 
Hyperemesis  lactantium,  133 

Imperfoeation,  duodenum,  209 

oesophagus,  129,  179 
Inspection,  57 
Intercostal  nerve,  lower,  2 
Intestinal  absorption,  41 

digestion,  37 
Intestine,  bacteria,  42 

large,  movements,  50 

small,  movements,  49 
Invertase,  40 

Jaworski's  sign,  191 
Jejuno-colic  fistula,  440 
Jejunostomy,  120,  407 

for  carcinoma  of  stomach,  296,  300 
Jejunum,  peptic  ulcer  of,  431 

"Kissing  ulcer,"  73 
Klemperer  oil  test,  49 


464 


Index. 


Lactase,  40 

Laparotomie  blanche,  129 
Lavage  of  stomach,  62 
Leiomyoma  malignum,  stomach,  217 
Lieberkiihn's  glands,  32 
Ligament,  cystico-colic,  20 

falciform,  3 

of  Treitz,  28 

suspensor}-,  of  liver,  3 
Linitis,  plastic,  234 

suppurative,  249 
Lipoma,  stomach,  226 
Liver,  blood-supply,  22 

developement,  7 

hemorrhage,  45 

ligament,  falciform,  3 
suspensory,  3 

lymphatics,  24 

nerv'es,  24 

physiology,  43 

position  of,  4 

pouch,  26 

topographical  anatomy,  17 

veins,  22 
Loreta's  operation,  112 
Lymphadenoma,  stomach,  232 
Lymphatics  of  liver,  24 

of  stomach,  13 

McGraw's  ligature,  373 

Mackenzie,  viscero-muscular  reflex,  3 

McLean  needle,  374 

Maltase,  40 

Mam  man.-  arter)%  internal,  2 

Myoma,  stomach,  214 

operations,  218 
Myosarcoma,  stomach,  217 
Myxomyoma,  stomach,  216 

Nerve,  intercostal,  lower,  2 

phrenic,  26 

pncumogastric,  14 
Nerves  of  liver,  25 

of  stomach,  symjjathetic,  14 

Obstruction,  portal,  24 

pylorus,  133 
(T-gagropile,  333 

CKsophagus,  imperforation,  129,  179 
Omentum,  great,  developement,  12 
Operations,  after-treatment,  348 

ana-sthctic,  342 

assistants,  343 

closure  of  wound,  346 

complications,  41 1 

death  after,  4 1 1 


Operations,  duodenostom)',  408 
entero-anastomosis,  381 
excision  of  stomach,  391 
exclusion  of  pylorus,  384 
gastrectomy,  390 

circular,  390 

cylindrical,  391,  403 

partial,  390 

Billroth's  second,  396 
Kocher's,  393 

subtotal,  390,  401 

total,  390,  402 
gastric  resection,  391,  404 
gastro-anastomosis,  387 
gastro-duodenostomy,  Kocher's,   367 
gastro-gastrostomy,  387 
gastro-jejunostomy,  368 

anterior,  371 

McGraw  ligature,  374 

posterior,  in-Y,  383 
long-loop,  375 
no  loop,  381 
gastropexy,  388 

Bevea's,  389 

Diiret's,  388 
gastroplasty,  3S6 
gastroplication,  388 
gastrostomy,  353 

Herzen's,  360 

Kader's,  356 

Roux's,  358 

Senn's,  355 

Ssbanajew-P'rank,  357 

Tavel's,  357 

Witzel's,  354 
gastrotomy,  351 
gauze  packs,  343 
hemorrhage,  414 
instruments,  343 
jejunostomy,  407 
Murphy  button,  343 
peritonitis,  416 
plastic  resection,  391 
pneumonia  after,  414 
preparation,  341 
pylorectomy,  390 

Billroth's  first,  391 
pyloroplasty,  362 

Durante's,  366 

Finney's,  362 
sequels,  411 
shock  after,  413 
sjthincterectomy,  390 
sul)])hrenic  abscess,  450 
sutures,  344 
te(hni(|ue,  341 
vicious  circle,  419 
Osteoma,  stomach,  232 


Index. 


465 


Pain  in  gastric  ulcer,  76 

referred,  3,  26 
Palpation,  57 
Pancreas,  blood  supply,  29 

position,  5 

topographical  anatomy,  28 
Pancreatic  juice,  37 
Papilla  of  Vater,  22 
Papilloma,  stomach,  221 
Para-umbilical  veins,  23 
Pathology,  clinical,  ulcer,  stomach,  73 
Pepsin,  36 

Peptic  ulcer,  post-operative,  431 
Percussion,  58 
Perforation  in  ulcer,  duodenum,  203 

stomach,  82 

diagnosis,  89 
symptoms,  86 
Perigastric  abscess,  85 
Perigastritis,  163 
Peritoneum,  embrv^ology,  6 
Peritonitis,  post-operative,  416 
Phrenic  nerve,  26 
Physiology,  applied,  51 

of  digestion,  31 

of  liver,  43 
Pneumogastric  nerve,  14 
Pneumonia,  post-operative,  414 
Polyadenomata,  stomach,  222 
"Polyadenome  en  nappe,"  223 
Polyposis,  stomach,  223 
Polypus,  stomach,  221 

mucous,  222 
Portal  obstruction,  24 

vein,  23 
Ptyalin,  35 
Pylorectomy,  390 

Billroth' s  first,  391 

"deadly  angle,"  393 
Pyloric  artery,  12 
Pylorodiosis,  112 
Pyloroplasty,  362 

Durante's,  366 

Finney's,  113,  362 
Pylorospasm,  143 
Pylorus,  divulsion,  112 

exclusion,  173,  384 

hypertrophy,  congenital,  133 

obstruction,  133 

stenosis,  infantile,  133 
aetiology,  134 
prognosis,  138 
symptoms,  137 
treatment,  139 

Rectus  muscle,  atroph}^  2 

Referred  pain,  3 

Reflex,  gastro-duodenal,  422 


Reflex,  viscero-muscular,  3 
Reflux  vomiting,  419 
Rennin,  37 
Resection  of  cardia,  405 

of  stomach,  391 
plastic,  391 
Roentgen  ray,  62 
Rupture,  diaphragm,  313 

duodenum,  338 

gastro-epiploic  artery,  331 

stomach,  326 

Saliva,  35 

Salivary  digestion,  35 
Salomon's  test,  281 
Sarcoma,  duodenum,  308 
stomach,  303 

diagnosis,  305 
operations,  306 
prognosis,  305 
symptoms,  304 
treatment,  305 
Sclerosis  of  stomach,  234 
Secretin,  40 

Shock,  post-operative,  413 
Shoulder  tip  pains,  26 
Skiagraphy,  62 
Sphincter,  antrum  pylori,  16 

duodenum,  28 
Sphincterectomy,  390 
Stab- wound,  diaphragm,  310 
operations,  312 
duodenum,  337 
gastro-epiploic  arter}-,  318 
stomach,  315 
Steapsin,  38 

Stenosis,  duodenum,  209 
pylorus,  infantile,  133 
aetiology,  134 
operations,  140 
prognosis,  138 
symptoms,  137 
treatment,  139 
Stomach,  abscess,  330 
adenoma,  221 

operations,  224 
angeioina,  232 
angeio-sarcoma,  217 
bacteria,  42 
benign  diseases,  67 
blood  supply,  12 
carcinoma,  268 
cctiology,  268 
diagnosis,  282 

by  .T-ray,  64 
duodenostom}-,  296,  300 
gastrectomy,  286 
cylindrical,  300 


466 


Ind 


ex. 


Stomach,  carcinoma,  gastrectomy,  partial, 
299 

subtotal,  297 

total,  297 
gastro-jejunostomy,  293 
gastrostomy,  296,  300 
Glutzlnsky's  test,  281 
hsemolytic  blood  test,  281 
histolog}',  271 
jejunostomy,  296,  300 
metastasis,  274 
prognosis,  285 
resection,  300 
Salomon's  test,  281 
symptoms,  278 
treatment,  297 
cardiac  orifice,  16 

cicatricial    contraction    of, 

185 
cirrhosis,  234 
concretions,  232 
cyst,  228,  330 

degeneration,  229 
dermoid,  228 
gaseous,  230 
hydatid,  228 

lymphangeiomatous,  229 
operations,  230 
retention,  228 
traumatic,  228 
digestion,  35 
dilatation,  146 
acute,  147 

diagnosis,  152 
operations,  155 
pathology,  149 
prognosis,  153 
symptoms,  151 
treatment,  153 
atonic,  157 

treatment,  159 
secondary,  161 
diagnosis,  168 
pathology,  163 
prognosis,  171 
symptoms,  165 
treatment,  172 
diverticula,  186,  198 
endothelioma  carcinomatosum,  304 
fibroma,  214 
foreign  body,  332 

gastrotomy,  334 
gastritis,  phlegmonous,  249 
gumma,  245 
hematoma,  330 
hair-tumor,  333 
hour-glass,  186 

clinical  pathology,  187 


Stomach,  hour-glass,  congenital,  18 

gastrectomy,  195 

gastro-gastrostomy,  193 

gastro-jejunostoni}',  194 

gastroplasty,  192 

Jaworski's  sign,  191 

operations,  196 

symptoms,  190 

treatment,  191 

vohoilus,  1 88 

Wolfler's  sign,  191 
injuries,  315 

after-effects,  331 
lavage,  62 

leiomyoma  malignum,  217 
lipoma,  226 
lymphadenoma,  232 
lymphatics,  13 
motor  power,  49 
movements,  47 
myoma,  214 
myosarcoma,  217 
myxomyoma,  216 
neoplasm,  benign,  213 
nerves,  sympathetic,  14 
obstruction  of  cardia,  179 
oegagropile,  333 
osteoma,  232 
papilloma,  221 

"paradoxical  dilatation,"  191 
polyadenomata,  222 
"polyadenome  en  nappe,"  223 
polyposis,  223 
polypus,  221 

mucous,  222 
posterior  wall,  exposure,  15 
relations,  5 
rotation,  10 
rupture,  326 

interstitial,  330 

spontaneous,  326 

traumatic,  328 
sarcoma,  303 

diagnosis,  305 

operations,  306 

prognosis,  305 

symjjtoms,  304 

treatment,  305 
sclerosis,  234 
syphilis,  245 

operations,  247 
syphiloma,  245 
topographical  anatomy,  12 
trie  hoi  )e/.oar,  333 
tulje,  Oo 
tuberculosis,  238 

operations,  242 
ulcer,  67 


Inde 


X. 


467 


Stomach,  ulcer,  aetiology,  67 
callous,  95 
chronic,  95 
cicatrizing,  95 
excision,  116 
frequency,  68 
htcmatemesis,  78 
hemorrhage,  80 
prognosis,  no 
treatment,  120 
hyperacidity,  79 
"kissing,"  73 
open,  76 
operations,  112 
pain,  76 
perforation,  82 
diagnosis,  89 
prognosis,  in 
treatment,  122 
predisposing  causes,  68 
prognosis,  100 
site,  73 

S3^mptoms,  76 
syphilitic,  70 
toxemic  origin,  70 
treatment,  112 
tuberculous,  70 
typhoid,  70 
A'omiting,  78 
veins,  12 
volvulus,  253 

operations,  255 
wound,  gunshot,  319 

treatment,  322 
stab,  315 

operations,  318 
Stricture,  duodenum,  209 

congenital,  209 
Subphrenic  abscess,  85,  443 
Succus  entericus,  40 
Syphilis  of  stomach,  245 
operations,  247 
Syphiloma  of  stomach,  245 

Technique  of  operations,  341 
Teeth,  the,  51 
Test  meal,  60 
Tetany,  gastric,  166 
Treitz,  ligament,  28 
Trichobezoar,  333 
Trypsin,  38 
Tube,  stomach,  60 
Tuberculosis,  stomach,  238 
operations,  242 

Ulcer,  duodenum,  200 

"hunger  pain,"  203 
operations,  206 


Ulcer,  duodenum,  perforation,  201 

prognosis,  205 

symptoms,  202 

treatment,  206 
jejunum,  peptic  ulcer  of,  431 
stomach,  67 

aetiology,  67 

age  in,  68 

callous,  95 

chronic,  95 

cicatrizing,  95 

classification,  67 

clinical  pathology,  73 

diagnosis,  95 

excision,  116 

exciting  causes,  70 

frequency,  68 

hffimatemesis,  78 

hemorrhage,  80 
prognosis,  no 
treatment,  120 

hyperacidity,  79 

"kissing,"  73 

open,  76 

opeTations,  112 

pain,  76 

perforation,  82 
diagnosis,  89 
prognosis,  in 
treatment,  122 

predisposing  causes,  68 

prognosis,  100 

site,  73 

symptoms,  76 

syphilitic,  70 

toxsemic  origin,  70 

treatment,  112 

tuberculous,  70 

typhoid,  70 

vomiting,  78 


Vater,  ampulla,  22 

papilla,  22 
Vein,  portal   23 
Veins  of  liver,  22 

para-umbilical,  23 
of  stomach,  12 
Vicious  circle,  419 
causes,  421 
symptoms,  423 
treatment,  424 
Viscero-muscular  reflex,  3 
Volvulus,  stomach,  253 

operations,  255 
Vomiting,  mechanism  of,  49 
reflux,  419 
in  ulcer  of  stomach,  78 


+68 


Index. 


Wolfler"s  sign  in  hour-glass  stomach,  191       Wound,  stab,  gastro-epiploic  artery,  31S 
Wound,  gunshot,  diaphragm,  313 


duodenum, 

stomach,  319 
operative,  diaphragm,  314 
stab,  diaphragm,  310 

duodenum,  337 


stomach,  315 

X-RAY,  62 
ZUCKERGUSSMAGEN, 234 


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